Recurring concern

Failure to provide required mealtime supervision

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First reported 29 Mar 2016•Latest report 19 Feb 2026

Definition

What this concern includes

Includes failures of the mealtime supervision process, including supervision during eating, movement between mealtime areas, and required one-to-one or line-of-sight observation, where the supervision is needed to manage an identified safety risk.

Not included

  • Excludes failures to record mealtime strategies or food and fluid intake when supervision itself is not deficient.
  • Excludes inadequate staffing or communal-area supervision not specifically tied to required mealtime supervision.
  • Excludes failures in choking response, emergency training or equipment unless they also demonstrate failure to provide required mealtime supervision.
  • Excludes general failures to provide meals, nutritional assistance or patient care that are not specifically about supervision during mealtimes.
Reports
6

Distinct published reports

Individual concerns
7

A report can raise multiple concerns

Date range
2016–2026

First to latest report issue date

Stated actions
4

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
Aria Healthcare Group Ltd1
Bolton Borough Council1
Care Quality Commission1
Cedar House Nursing and Residential Home1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Mental Health NHS Foundation Trust1
Harbour Healthcare Ltd.1
Hc-One Limited1
Hilltop Court Nursing Home1
NHS England1
Royal Bolton Hospital1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Northamptonshire

    AI-generated summary

    Jane Ann FENWICK · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jane Ann Fenwick died on 21 August 2025 at Kettering General Hospital after choking on a piece of beef at her care home. She had no teeth, did not wear dentures, tended to rush and overfill her mouth, preferred softer food, and had a care plan identifying a choking risk. The principal concerns were the threshold for Speech and Language Therapy intervention and support, and the waiting time for that support, despite her identified risks and lack of supervision while eating.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to supervise people while eating in accordance with care plans

    Wider context from the report

    “Mrs Fenwick:- a) had no teeth b) did not wear her dentures c) had a tendency to rush her food d) had a tendency to put too much in her mouth e) had poor posture and generally did not sit at a table to eat f) did not sit still g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating) h) had a preference for softer food i) had a care plan which identified a risk of choking Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking. The care home also said in evidence that the average wait for SALT support is 13 weeks. I have concerns regarding the threshold for intervention/support and the current waiting lists. ”

    Source location

    Jane Ann FENWICK · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Fund eligible adult social care staff to undertake nutrition, hydration, choking prevention and response training through the Learning and Development Support Scheme.

    Verbatim wording from the response

    “Any form of neglect is unacceptable, and my department recognises the importance of safe, person-centred care, particularly in relation to eating and drinking. This is why the Adult Social Care Learning and Development Support Scheme (LDSS), was launched in September 2024, and provides funding for eligible care staff to undertake courses and qualifications, including the Level 2 Certificate in Understanding Nutrition and Health and relevant content in the Level 2 Adult Social Care Certificate (L2ASCC).”

    Source location

    2026-0104 - Response from Department of Health and Social Care
    Page 1 · response
    Published 24 February 2026

    Open published response

  2. Essex

    AI-generated summary

    Elise Kay Louise Sebastian · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elise Kay Louise Sebastian tied a fatal ligature in her room on Longview Ward on 17 April 2021 and died two days later in hospital. The principal concerns included inadequate and falsified observations, insufficiently trained and staffed ward personnel, poor communication about ligaturing and self-harm, medication-recording errors, failures involving Oxevision, and other care and record-keeping deficiencies.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequate supervision of patients moving between areas at mealtimes

    Wider context from the report

    “6. Detained patients including Elise were not kept under observations by trained staff and mealtimes were chaotic with patients moving between areas without the required supervision. On 17 April the activity co-ordinator left a box of mobile phone chargers and headphones that posed a ligature risk, with a member of ward staff in a communal area, asking that she look after this whilst he collected some takeaway food that had been ordered by patients from the ward entrance. On his return, the box was unattended in the presence of patients with a high risk of ligature and suicide, with no member of ward staff present to keep patients who required level 2 and level 3 observations. This was not reported to the nurse in charge, and no incident report was completed. Evidence was that there were many new staff and that breaches of procedure were a regular occurrence. This left patients at risk. Evidence was heard that patients are still being left without the required observations since this death. ”

    Source location

    Elise Kay Louise Sebastian · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Barry Wayne Preston · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to supervise eating when supervision is required

    Wider context from the report

    “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort. ”

    Source location

    Barry Wayne Preston · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.

    Verbatim wording from the response

    “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.”

    Source location

    2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 1 · response
    Published 9 June 2020

    Open published response

  4. Nottinghamshire

    AI-generated summary

    George Goldby · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and reviews.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to supervise residents at high risk of choking during eating

    Wider context from the report

    “(8) Between 19.09.17 and 18.10.17 three separate independent professionals observed residents at high risk of choking eating alone, without supervision. ”

    Source location

    George Goldby · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide one-to-one mealtime supervision for residents at choking risk

    Wider context from the report

    “(2) Mr Goldby’s SALT recommendations were not being adhered to on 26.12.16 when he choked and recovered, nor on 20.03.17 when he choked again, directly leading to his death. Mr Goldby was not supervised one to one during his mealtimes. ”

    Source location

    George Goldby · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Allocate staff and provide practical supervision during residents’ eating and drinking.

    Verbatim wording from the response

    “1. Allocation of staff to and practical supervision of Residents whilst eating and drinking to assess any issues.”

    Source location

    2018-0104-Response-by-HC-One
    Page 1 · response
    Published 17 June 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Commission a three-day face-to-face dysphagia course for the home’s staff from an external expert provider.

    Verbatim wording from the response

    “We believe that there is no substitute for repeated learning opportunities that help inform staff of the consequences of not supporting Residents effectively and to that end have commissioned a three day face to face dysphagia course for the staff team from an external expert training provider. This is to supplement and extend the learning opportunities already available and refreshed by the team via our online award winning learning platform, Touchstone.”

    Source location

    2018-0104-Response-by-HC-One
    Page 2 · response
    Published 17 June 2018

    Open published response

  5. Manchester South

    AI-generated summary

    Barbara Haley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barbara Haley inhaled vomit, saliva, food or liquid while resident at Hilltop Court Care Home, developed a chest infection, and died at Stepping Hill Hospital on 13 October 2017 after suffering a cardiac arrest en route. Concerns included her being provided food unsuitable for her soft diet and being left alone to eat despite having been assessed as at high risk of choking.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to supervise high-risk residents while eating

    Wider context from the report

    “2. During the course of her evidence, ████████ (Home Manager) explained that Mrs Haley was assessed as being at High Risk of choking and scored high on the risk assessment that had been carried out. Despite this, Mrs Haley would be left alone in her room to eat because ████████ stated she did not like to have staff present when she was eating; she would then refuse to eat. We heard evidence from a manager at another home that Mrs Haley would eat when she was in the dining room with other residents, where staff could also observe her. It was of concern that Mrs Haley was being left alone in her room to eat when she had been assessed as being at the high risk of choking. ”

    Source location

    Barbara Haley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Norfolk

    AI-generated summary

    PAMELA JOYCE THURSTON · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Pamela Joyce Thurston, a resident of Cedar Care Home with Alzheimer's dementia, choked on toast after being given food following an approximately 17-hour period without eating and without direct supervision. She developed bronchopneumonia and died in hospital two days later. The substantive concerns included her not being given breakfast, the lack of direct supervision while eating, and the response to the choking incident.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide direct supervision during eating for residents who require it

    Wider context from the report

    “Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimer's dementia and required prompting in order to eat meals and also supervision in doing so. Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect. The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift. On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics. Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital. It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later. ”

    Source location

    PAMELA JOYCE THURSTON · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Record meal-service times and provide documented direct observation after missed meals or gaps of eight hours or more.

    Verbatim wording from the response

    “5. Ensure a tick list is in the kitchen area which documents the time a service user is served with a meal in the Home. Where it is noticed that a significant period of time has passed between meals for a service user (eight hours or over), or where a service user has missed a meal, direct observations of the service user should be maintained whilst the service user is eating their meal or snack. The person in charge must designate a member of staff to undertake the observation and this should be documented in the service users notes.”

    Source location

    Thurston-Response
    Page 2 · response
    Published 29 March 2016

    Open published response
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Data last updated 7 September 2026