First reported 30 Jul 2014•Latest report 19 Feb 2026
Definition
What this concern includes
Includes failures of controls dedicated to choking-risk prevention or response, including risk recognition, care-record accuracy, implementation of preventative measures, staff competence and application of choking guidance.
Not included
Excludes generic delays or failures to implement safety measures where they are not explicitly tied to choking risk.
Excludes unrelated clinical, care-planning or emergency-treatment deficiencies.
Excludes isolated equipment, staffing or documentation problems unless they directly concern choking-risk prevention or response.
Reports
25
Distinct published reports
Individual concerns
31
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
55
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 Care5
Care Quality Commission3
NHS England3
Department for Education2
Metropolitan Police Service2
Recipient name withheld2
Abbotswood1
Aran Court Care Centre1
Aspray House1
Aspray House Ltd1
Bedfordshire Police1
Boldmere Court Care Home1
Bourne Leisure Limited1
Bupa Care Homes (GL) Limited1
Care Outlook Ltd1
Ministerial department7
Private limited company7
Residential care home4
Executive non-departmental public body3
Health and social care service regulator3
Healthcare site3
Nursing home3
Police force3
Type not available3
NHS trust2
Education and care inspectorate1
Food safety regulator1
Health-system partnership1
Integrated care board1
Local-government membership body1
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.
Northamptonshire
Concerns raised1
Failure to refer people at risk of choking to Speech and Language Therapy for support and intervention
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local services determine SALT referral criteria and make referral decisions according to individual patient need.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Yorkshire and York
Concerns raised1
Failure to routinely check for patients' choking risks during handovers
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Maintain a sip-testing procedure and staff training, with Speech and Language Therapy referral after failed tests.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 December 2025.
Action
Roll out Nervecentre with prominent alerts for recorded swallowing difficulties and recommended texture-modified diets.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 December 2025.
Action
Issue a clinical alert reinforcing explicit handover of known high-impact risks and documentation of verbal handover content.
Stated by Yorkshire Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2025.
Action
Review and update handover protocols where appropriate to reflect contemporary practice and learning from the case.
Stated by Yorkshire Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2025.
Action
Incorporate case learning into the monthly Patient Safety Bulletin and support local educational sessions for clinical staff.
Stated by Yorkshire Ambulance Service NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Emergency Department action for swallowing or choking risks is limited by patients’ clinical needs and what is operationally deliverable in a busy department.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The crew appropriately recorded and verbally handed over swallowing difficulty; it was historical background rather than an identified active or immediate choking risk.
Stated by Yorkshire Ambulance Service NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Routine verbalisation of choking risk for every patient is not operationally deliverable or proportionate and could cause information overload and missed pertinent details.
Stated by Yorkshire Ambulance Service NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised2
Failure to attempt abdominal thrusts for choking
Failure to administer effective back slaps for choking
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Purchase and use an Act Fast anti-choking trainer vest for practical training in back slaps and abdominal thrusts.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Action
Engage an external provider to assess choking competency individually for all 73 permanent and agency staff.
Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
Birmingham and Solihull
Concerns raised1
Lack of knowledge of anti-choking devices in care settings
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Care homes are responsible for deciding whether to purchase and use anti-choking devices; the ICB does not directly purchase them.
Stated by NHS Birmingham and Solihull Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
HSE considers anti-choking-device concerns outside its regulatory and policy-lead remit.
Stated by Health and Safety ExecutiveOutside remitThe respondent said that this matter was outside its role or authority.
Position
Regulation of care providers using anti-choking devices rests with CQC.
Stated by Health and Safety ExecutiveRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Regulation of anti-choking medical devices rests with MHRA.
Stated by Health and Safety ExecutiveRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Health and social care policy and delivery in England rests with DHSC.
Stated by Health and Safety ExecutiveRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex, Brighton and Hove
Concerns raised1
Failure to consider possible choking
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Purchase and use a choking vest for hands-on basic life support training.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Develop a lesson plan for practical choking recognition and response training using the choking vest.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Roll out standalone practical choking-response sessions using the choking vest across services.
Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 7 June 2024.
Action
Provide amended choking-vest training through mandatory induction and refresher basic life support sessions.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Action
Create and publish an online recorded choking-response training session with practical demonstrations for staff refreshers.
Stated by Care Outlook LtdStated in progressThe respondent said that this action was in progress when they made their response on 7 June 2024.
Action
Increase dysphagia and modified-diets e-learning refreshers to an annual frequency.
Stated by Care Outlook LtdStated completedThe respondent said that this action was complete when they made their response on 7 June 2024.
Central and South East Kent
Concerns raised1
Insufficient staff knowledge and training on baby weaning and safe nursery feeding
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Review and publish revised Level 3 Early Years Educator qualification criteria incorporating weaning and choking-prevention content.
Stated by Department for EducationStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Assess qualifications against the revised criteria and add approved qualifications to the Early Years Qualifications List.
Stated by Department for EducationStated in progressThe respondent said that this action was in progress when they made their response on 31 May 2024.
Action
Publish sector guidance on food safety, choking prevention and introducing babies to solid food.
Stated by Department for EducationStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Action
Complete the EYFS safeguarding consultation and use its findings to develop proposed safer-eating requirements.
Stated by Department for EducationStated completedThe respondent said that this action was complete when they made their response on 31 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Awarding organisations and training providers are responsible for developing and delivering qualification content that meets the Department’s early-years criteria.
Stated by Department for EducationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Blackpool and the Fylde
Concerns raised2
Delays in implementing necessary choking-risk preventative measures
Failure to appropriately assess and record choking risks for vulnerable service users
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Unavailability of suction machines in care homes for staff management of choking
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Somerset
Concerns raised1
Failure of staff to adequately recognise choking risks
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Absence of choking-related red flags in tonsillectomy guidance
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of controls dedicated to choking-risk prevention or response, including risk recognition, care-record accuracy, implementation of preventative measures, staff competence and application of choking guidance.
