19 Feb 2026 Jane Ann FENWICK · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Failure to refer people at risk of choking to Speech and Language Therapy for support and intervention View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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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.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to refer people at risk of choking to Speech and Language Therapy for support and intervention
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
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local services determine SALT referral criteria and make referral decisions according to individual patient need.
Verbatim wording from the response “The referral criteria for SALT is agreed locally, aligned to commissioning and service models but referral decisions should be based on an individual’s need. Not having a previous choking episode should not prevent a referral if the wider clinical history and risk of choking are recognised and included in the referral.” Source location 2026-0104 - Response from NHS England
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23 Dec 2025 Colin Richard BROWN · Prevention of Future Deaths report North Yorkshire and York
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Concerns raised 1
Failure to routinely check for patients' choking risks during handovers View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
York and Scarborough Teaching Hospitals NHS Foundation Trust Yorkshire Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
York and Scarborough Teaching Hospitals NHS Foundation Trust
Maintain a sip-testing procedure and staff training, with Speech and Language Therapy referral after failed tests.
View source
York and Scarborough Teaching Hospitals NHS Foundation Trust
Roll out Nervecentre with prominent alerts for recorded swallowing difficulties and recommended texture-modified diets.
View source
Yorkshire Ambulance Service NHS Trust
Issue a clinical alert reinforcing explicit handover of known high-impact risks and documentation of verbal handover content.
View source
Yorkshire Ambulance Service NHS Trust
Review and update handover protocols where appropriate to reflect contemporary practice and learning from the case.
View source
Yorkshire Ambulance Service NHS Trust
Incorporate case learning into the monthly Patient Safety Bulletin and support local educational sessions for clinical staff.
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Colin Richard BROWN · 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
Colin Richard Brown attended York Hospital Emergency Department on 28 March 2025 and choked on food provided by the hospital, leading to a cardiac arrest and transfer to intensive care. He died on 31 March 2025. The concerns were that his care plan was not transported to hospital and that information about his choking risk might not be reliably communicated or checked during the handover period.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to routinely check for patients' choking risks during handovers
Wider context from the report “During the inquest I heard evidence that confirmed that a copy of Mr Brown's care plan was not transported with him to hospital. There was mention in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk but there was a delay of approximately 25 minutes between Mr Brown being verbally handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the Core Patient Database and accessible to staff dealing with Mr Brown. Such a delay is usual and inevitable in these circumstances, allowing time, for example, to access a device to action the upload. However, during this 25 minutes the only information that is available is what is shared orally in the handover and noted down by hospital staff. This may not include reference to a patient being a choking risk either because it is not mentioned by the ambulance crew or, because it is not deemed necessary by the hospital staff to check or to note, particularly in circumstances where this is entirely unrelated to the presenting concern. The evidence before me was that a patient being a choking risk is not routinely checked during all handovers . It was accepted in evidence that patients may not reliably draw attention to this crucial information themselves , as was the case here.
” Source location Colin Richard BROWN · Prevention of Future Deaths report
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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 Maintain a sip-testing procedure and staff training, with Speech and Language Therapy referral after failed tests.
Verbatim wording from the response “Where new concerns are identified about a patient’s swallowing ability, the Trust has a Standard Operating Procedure (SOP) for Sip Testing in place along with training. This provides staff with guidance around how to complete a sip test to determine whether the patient is safe to eat and drink normally. If they fail the sip test e.g. due to coughing, no swallow, delayed or multiple swallows then they are referred to the Speech & Language Therapy (SALT) team for further advice and assessment to determine the most appropriate diet options for the patient.” Source location Response from York and Scarborough Teaching Hospital NHS Foundation Trust
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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 Roll out Nervecentre with prominent alerts for recorded swallowing difficulties and recommended texture-modified diets.
Verbatim wording from the response “The introduction of the Trust’s new electronic patient record (Nervecentre) is being rolled out from next month with expected completion in the autumn. This will include the option to have a prominent alert to highlight if a patient has a previously identified swallowing difficulty recorded in the system and what their recommended texture-modified diet should be. This information will therefore be clearly available at future attendances.” Source location Response from York and Scarborough Teaching Hospital NHS Foundation Trust
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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 Issue a clinical alert reinforcing explicit handover of known high-impact risks and documentation of verbal handover content.
Verbatim wording from the response “1. Clinical emphasis within handover guidance: YAS will issue a clinical alert to all staff to reinforce that known high-risk features not directly related to the presenting complaint (for example swallowing/choking risk, severe cognitive impairment, or behavioural risk) should be considered for explicit verbal handover where omission could reasonably result in harm and that clinicians document the contents of the verbal handover.” Source location Response from Yorkshire Ambulance Service NHS Trust
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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 Review and update handover protocols where appropriate to reflect contemporary practice and learning from the case.
Verbatim wording from the response “2. Review of handover protocols: YAS will review its handover protocols and update where appropriate to reflect contemporary practices and learning from this tragic case.” Source location Response from Yorkshire Ambulance Service NHS Trust
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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 Incorporate case learning into the monthly Patient Safety Bulletin and support local educational sessions for clinical staff.
Verbatim wording from the response “3. Targeted learning and awareness: Learning from this case will be incorporated into the monthly YAS Patient Safety Bulletin accessible to all clinical staff. These materials will also support local educational sessions (termed internally as ‘investment days’) and will emphasise professional judgement, advocating for the continued use of structured, succinct and clinically pertinent handover conversations.” Source location Response from Yorkshire Ambulance Service NHS Trust
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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 Emergency Department action for swallowing or choking risks is limited by patients’ clinical needs and what is operationally deliverable in a busy department.
Verbatim wording from the response “We follow principles of safe handover practice and balance all information received with the immediate emergency needs of the patient. If we are in receipt at handover of information regarding a significant risk such as severe previous swallowing difficulties or choking risk this will be considered within the assessment of any immediate care needs to help manage the emergency situation. Action will be taken which is proportionate to the patient’s clinical needs in balance with what is operationally deliverable in a busy Emergency Department. Such a significant risk would be recorded in the patient’s record to ensure continuity of care throughout the patient’s journey.” Source location Response from York and Scarborough Teaching Hospital NHS Foundation Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The crew appropriately recorded and verbally handed over swallowing difficulty; it was historical background rather than an identified active or immediate choking risk.
Verbatim wording from the response ““The information I have been provided shows the attending crew reported that Mr Brown did not disclose any requirement for a modified or soft diet to them, nor was any care plan or supporting documentation reported as existing or being provided, despite care notes within the bundle provided by HM Coroner stating Mr Brown required a modified diet. Furthermore, a collateral history was not obtainable as no carers or family members were at the scene. The ePR completed by the crew does include a past medical history entry noting previous swallowing difficulty. This reflects historical medical background obtained through them accessing the Summary Care Record for Mr Brown. This is part of routine history-taking and information gathering rather than identification of an active or clinically apparent risk at the time of ambulance assessment.” Source location Response from Yorkshire Ambulance Service NHS Trust
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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 Routine verbalisation of choking risk for every patient is not operationally deliverable or proportionate and could cause information overload and missed pertinent details.
Verbatim wording from the response ““It is not feasible, nor clinically proportionate, for ambulance clinicians to identify and verbally communicate all potential secondary risks for every patient during every handover, particularly where these are longstanding conditions documented elsewhere and unrelated to the reason for conveyance. Adopting an approach such as this increases risk of key clinical information being missed and prolongs the handover process, meaning crews will be unable to respond to further emergencies. This is reflected in national guidance and contemporary literature advocating for structured, succinct handover. Structured handover therefore represents a balance between completeness and safety, aligned with human-factors principles and the avoidance of information overload.” Source location Response from Yorkshire Ambulance Service NHS Trust
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21 Jul 2025 Madeline Reding · Prevention of Future Deaths report East London
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Concerns raised 2
Failure to attempt abdominal thrusts for choking View source Failure to administer effective back slaps for choking View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Aspray House
Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
View source
Aspray House
Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.
View source
Aspray House
Purchase and use an Act Fast anti-choking trainer vest for practical training in back slaps and abdominal thrusts.
View source
Aspray House
Engage an external provider to assess choking competency individually for all 73 permanent and agency staff.
View source See 1 more action
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AI-generated summary
Madeline Reding · 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
Madeline Reding, a 79-year-old nursing-home resident with advanced vascular dementia, became unwell after lunch on 17 May 2024, regurgitated food, developed an upper-airway obstruction and respiratory arrest, and died that afternoon. The inquest identified delayed and disorganised staff responses, including a failure to sound the emergency alarm or make an immediate 999 call, delayed CPR, and ineffective first aid.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to attempt abdominal thrusts for choking
Wider context from the report “5. First aid that was administered was ineffective.
a. Back slaps were weak
b. Abdominal thrusts were not attempted
c. Chest compressions were only commenced over ten minutes after Mrs Reding was found to have stopped breathing.
” Source location Madeline Reding · Prevention of Future Deaths report
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 administer effective back slaps for choking
Wider context from the report “5. First aid that was administered was ineffective.
a. Back slaps were weak
b. Abdominal thrusts were not attempted
c. Chest compressions were only commenced over ten minutes after Mrs Reding was found to have stopped breathing.
” Source location Madeline Reding · Prevention of Future Deaths report
Open source report
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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 Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
Verbatim wording from the response “Immediately following the incident, an urgent flash Lessons Learnt training session was held with all nursing staff (including the management nurses present at the incident) on 23 May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, Resuscitation and DNARCPR policies and the procedures to be followed in the event of a choking incident. Both policies were subsequently reviewed on 31 July 2024 and noted to be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.” Source location 2025-0368 Response from Aspray House Nursing Home
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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 Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.
Verbatim wording from the response “Senior management designed a simple to follow colour coded Choking Flow Chart in October 2024 which is compliant with current guidance and which has been placed on display in all nursing stations throughout Aspray House reinforcing the policy, procedure and expectations of how all staff should deal with choking situations – including highlighting that CPR must be attempted if suitable even on residents with a DNAR in place. This has been supplemented with a pictorial Choking First Aid poster for universal understanding which has been displayed in all dining areas.” Source location 2025-0368 Response from Aspray House Nursing Home
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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 Purchase and use an Act Fast anti-choking trainer vest for practical training in back slaps and abdominal thrusts.
Verbatim wording from the response “In October 2024, Aspray House also purchased an Act Fast Anti Choking Trainer Vest for use in practical training to ensure that all staff are proficient in back slaps and abdominal thrusts. Students wear the Choking Vest to learn the correct manoeuvres which when performed correctly shoots a foam plug into the air. It also includes a foam back slap pad for practicing effective back slaps. Thus, making instruction realistic and leaving participants confident in their actions and their response to a genuine choking incident should one occur.” Source location 2025-0368 Response from Aspray House Nursing Home
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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 Engage an external provider to assess choking competency individually for all 73 permanent and agency staff.
Verbatim wording from the response “Following a subsequent meeting with the Local Authority and taking on board its concerns that all post-incident training competences and assessments were conducted in-house, Aspray House also engaged a private training provider – Michael Hughes Training - to assess its staffs’ competency in choking training. This training was undertaken on a two-day rotation on 21 and 31 March 2025 with individual assessments conducted with all 73 staff members working at the home (both permanent and agency staff). We confirm that all staff members successfully passed the course.” Source location 2025-0368 Response from Aspray House Nursing Home
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24 Jan 2025 Neville Daniel Elisha MCKENZIE · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Lack of knowledge of anti-choking devices in care settings View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Health and Safety Executive NHS Birmingham and Solihull Integrated Care Board
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AI-generated summary
Neville Daniel Elisha MCKENZIE · 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
Neville Daniel Elisha MCKENZIE died in hospital on 25 August 2024 after choking at his care home on 13 August 2024, which led to cardiac arrest and an unsurvivable brain injury. The report raised concerns about limited awareness and availability of anti-choking devices in care settings, including homes with residents at high risk of choking.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of knowledge of anti-choking devices in care settings
Wider context from the report “1. The inquest heard evidence from ████████, Director of Operations for 1st Care Limited, the company which owns Acorn Care Home where Mr McKenzie was a resident. ████████ explained that since Mr McKenzie's death they have purchased a number of anti choking devices and provided training to all staff on the use of them as part of their first aid training. This arose from investigations and research carried out by 1st Care Limited to try and avoid a fatal incident occurring again. Prior to Mr McKenzie's death 1st Care Limited had no knowledge of the availability of these devices. ████████ explained that there is no legal or regulatory requirement for Care or Nursing Homes to have these devices available.
2. ████████, who has considerable experience working in health and social care, said she was concerned that there was not wider knowledge of the existence of these devices particularly for homes that have a high volume of residents with choking risks like Acorn Care Home .
3. I heard evidence that the devices are relatively inexpensive and do not require extensive training.
4. ████████ evidence was that she felt the devices could save lives in the event of choking incidents and the fact that most homes would not have them, even those with a high risk resident cohort, was creating an avoidable risk of deaths.
5. It was my finding that there is not wide knowledge of the availability of these devices in care settings and if more homes had them it is likely that deaths from choking could be reduced.
” Source location Neville Daniel Elisha MCKENZIE · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Care homes are responsible for deciding whether to purchase and use anti-choking devices; the ICB does not directly purchase them.
Verbatim wording from the response “The ICB does not directly purchase anti-choking devices for care homes. However, we are committed to ensuring that care homes have the information and support they need to make informed decisions about whether to purchase and use these devices, in alignment with Resuscitation Council UK (RCUK) guidelines. The ICB adheres to the RCUK guideline which emphasises that any use of anti-choking devices should be adjunctive to, and not a replacement for, the established techniques recommended by the RCUK for managing choking, which include encouraging coughing, back blows, and abdominal thrusts.” Source location Response from Birmingham and Solihull Integrated Care Board
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HSE considers anti-choking-device concerns outside its regulatory and policy-lead remit.
Verbatim wording from the response “Following consideration of these factors, I respectfully advise that HSE is not the appropriate regulator or policy lead to address this concern relating to anti-choking devices because:” Source location Response from HSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulation of care providers using anti-choking devices rests with CQC.
Verbatim wording from the response “• 1st Care Limited are a service provider registered with the Care Quality Commission (CQC), and therefore regulation of this and similar care providers falls under their enforcement responsibility” Source location Response from HSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Regulation of anti-choking medical devices rests with MHRA.
Verbatim wording from the response “• anti-choking devices are medical devices for which the Medicines & Healthcare products Regulatory Agency (MHRA) are the UK regulator” Source location Response from HSE
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Health and social care policy and delivery in England rests with DHSC.
Verbatim wording from the response “• the Department of Health and Social Care (DHSC) are the government department that leads on health and social care policy and delivery in England.” Source location Response from HSE
Open published response
Concerns raised 1
Failure to consider possible choking View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Care Outlook Ltd
Purchase and use a choking vest for hands-on basic life support training.
View source
Care Outlook Ltd
Develop a lesson plan for practical choking recognition and response training using the choking vest.
View source
Care Outlook Ltd
Roll out standalone practical choking-response sessions using the choking vest across services.
View source
Care Outlook Ltd
Provide amended choking-vest training through mandatory induction and refresher basic life support sessions.
View source
Care Outlook Ltd
Create and publish an online recorded choking-response training session with practical demonstrations for staff refreshers.
View source
Care Outlook Ltd
Increase dysphagia and modified-diets e-learning refreshers to an annual frequency.
View source See 3 more actions
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AI-generated summary
Alan Richard LEE · 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
On 17 December 2023, Alan Richard LEE choked on a food bolus after being given dinner in his flat and died before the ambulance arrived. Staff who attended did not appear to recognise that he may have been choking, so no lifesaving techniques were attempted.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider possible choking
Wider context from the report “The issue of concern is that despite the fact that Mr Lee had recently been given his dinner and there was evidence that some or part of it had been consumed, the staff who attended, following Mr Lee using his alarm, did not appear to consider that he may have been choking . Therefore, no life saving techniques were attempted.
” Source location Alan Richard LEE · Prevention of Future Deaths report
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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 Purchase and use a choking vest for hands-on basic life support training.
Verbatim wording from the response “Action | Detail
Purchase of a choking vest | The training team purchased a Choking Vest to incorporate into the practical BLS training we deliver.” Source location Response from Care Outlook
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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 Develop a lesson plan for practical choking recognition and response training using the choking vest.
Verbatim wording from the response “Development of training plan | The training team developed a lesson plan for the delivery of the additional practical element of the choking training which can be delivered as a standalone session and can be incorporated into the existing BLS training session currently delivered during induction and refresher training.” Source location Response from Care Outlook
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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 Roll out standalone practical choking-response sessions using the choking vest across services.
Verbatim wording from the response “Action | Detail
Roll out of training with choking vest | The new practical session was rolled out to services as a standalone session beginning on 01/07/2024.” Source location Response from Care Outlook
Open published response
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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 Provide amended choking-vest training through mandatory induction and refresher basic life support sessions.
Verbatim wording from the response “Incorporation of choking vest training to induction and refresher | As noted above the lesson plan created by the training team can be delivered standalone or as part of the existing mandatory BLS training delivered during induction and refresher training.” Source location Response from Care Outlook
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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 Create and publish an online recorded choking-response training session with practical demonstrations for staff refreshers.
Verbatim wording from the response “In addition, the training team are creating a recorded session with practical demonstrations using the choking vest which will be available to all staff across the business online and will be accessible at any time for refreshers via our e-learning platform. The recording has been completed and is now in the editing stages with the intention to have this live on the system before the end of August 2024.” Source location Response from Care Outlook
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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 Increase dysphagia and modified-diets e-learning refreshers to an annual frequency.
Verbatim wording from the response “Increased frequency of e-learning | All staff complete e-learning on Dysphagia and Modified Diets as part of their Induction. This training has been set to an increased refresher frequency of annually.” Source location Response from Care Outlook
Open published response
Concerns raised 1
Insufficient staff knowledge and training on baby weaning and safe nursery feeding View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Department for Education
Review and publish revised Level 3 Early Years Educator qualification criteria incorporating weaning and choking-prevention content.
View source
Department for Education
Assess qualifications against the revised criteria and add approved qualifications to the Early Years Qualifications List.
View source
Department for Education
Publish sector guidance on food safety, choking prevention and introducing babies to solid food.
View source
Department for Education
Complete the EYFS safeguarding consultation and use its findings to develop proposed safer-eating requirements.
View source See 1 more action
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AI-generated summary
Oliver Steeper · 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
Oliver Steeper choked on finely chopped pasta bolognaise at a nursery on 23 September 2021 and died on 29 September 2021 after suffering a hypoxic/ischaemic brain injury. The report raises concerns about the number and validity period of paediatric first-aid qualifications available at nurseries, the standard of first aid provided, and staff education and systems for assessing and recording babies’ weaning stages.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient staff knowledge and training on baby weaning and safe nursery feeding
Wider context from the report “3. Staff Education Regarding Weaning Stages
Evidence has been heard during the course of the inquest concerning nursery staffs' understanding of the different stages of weaning that a child moves through. It was not clear that staff appreciated the importance of mirroring weaning at home with weaning at nursery. Staff (and systems) did not appear to ensure that detailed and accurate information about a child’s individual weaning stage was elicited from parents, recorded, audited, reviewed and applied. It was not clear that staff appreciated the importance of eliciting and recording this detailed information from the family.
Despite staff members having levels 1, 2 and 3 Diplomas in Childcare and Education, there was limited evidence of any knowledge or training on the stages of baby weaning and the risk of a child choking on food . As such, it is not clear that the content of those qualifications adequately covers stages of weaning and how to safely wean in the nursery environment . Even if the training does cover this, it is not apparent that any refresher training is provided to nursery staff holding these qualifications, to ensure that they are up to date in their knowledge, i.e. continuing professional development.
” Source location Oliver Steeper · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and publish revised Level 3 Early Years Educator qualification criteria incorporating weaning and choking-prevention content.
Verbatim wording from the response “19. The Level 3 Early Years Educator (EYE) qualifications criteria were recently reviewed in order to improve the quality of the criteria and by extension the quality of early years qualifications at Level 3 and above, and ensure better-quality care for children as a result. Following the review and subsequent public consultation, the Department published the new Level 3 EYE qualifications criteria in April 2023. The new criteria can be found at Annex E of the Early years qualification requirements and standards document and will come into effect from 1 September 2024.” Source location Response from Department for Education
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess qualifications against the revised criteria and add approved qualifications to the Early Years Qualifications List.
Verbatim wording from the response “20. Following the publication of the new EYE criteria, the Department asked awarding organisations and training providers to update their qualifications at Levels 3, 4, 5, 7 and 8*2 to meet the new criteria and submit them to DfE for assessment and approval by September 2024, in order to remain on the EYQL after September 2024. These qualifications must then be delivered for “first teach” for new learners by September 2025 at the latest, so that new learners starting on a qualification from September 2025 take on an approved qualification. As part of its business-as-usual activity, the Department is currently in the process of approving qualifications against the new criteria and will be adding approved qualifications to the EYQL by September 2024.” Source location Response from Department for Education
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish sector guidance on food safety, choking prevention and introducing babies to solid food.
Verbatim wording from the response “26. In addition to the EYFS statutory requirements, we have also produced information for the sector regarding food safety and choking prevention which was published in July 2021, and introducing babies to solid food which was published in March 2024. This can be found on the DfE owned “Help for early years provider’s” platform:” Source location Response from Department for Education
Open published response
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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 Complete the EYFS safeguarding consultation and use its findings to develop proposed safer-eating requirements.
Verbatim wording from the response “12. The requirements outlined above when implemented together should ensure that there is a PFA member of staff available and ready to respond to incidents quickly. However, the Department recognises the importance of staff members being PFA trained, especially whilst children are eating, which is why in the recent EYFS safeguarding consultation which closed on 17 June 2024, we have put forward the following proposals:” Source location Response from Department for Education
Open published response
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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 Awarding organisations and training providers are responsible for developing and delivering qualification content that meets the Department’s early-years criteria.
Verbatim wording from the response “17. The Department sets the standards (the early years qualifications criteria) which underpin early years qualifications. The qualifications criteria we hold are the Level 2 Early Years Practitioner criteria, and the Level 3 Early Years Educator criteria, and can be found in the Early Years Qualifications and Standards document.” Source location Response from Department for Education
Open published response
21 Jul 2023 Steven Duquemin · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2
Delays in implementing necessary choking-risk preventative measures View source Failure to appropriately assess and record choking risks for vulnerable service users View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Steven Duquemin · 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
Steven Duquemin, a vulnerable man, died after choking on a large piece of raw chicken that he attempted to eat overnight while no carer staff were present. The report identified inconsistent care-record entries and an under-appreciation of his choking risk, with concern that necessary preventative measures might not be implemented promptly for other vulnerable service users.
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 Delays in implementing necessary choking-risk preventative measures
Wider context from the report “• Entries in care records were inconsistent, some indicating Steven was not at risk of choking when he clearly was at such risk, and indeed one member of staff gave credible evidence that she had on one occasion have to use skills learned at some recent training to assist Steven after he overfilled his mouth with food.
• My concern is quite straight-forward. I received evidence from a Service Manager. In my judgement, in the face of quite overwhelming evidence to the contrary – including a clear medical cause of death reported by the Pathologist - ████████ continued to maintain that Steven had not been at risk of choking, and appeared to stand by entries in care records to the extent they indicated he had not been at risk of choking.
• As I indicated at the conclusion of the inquest, it appeared to me that ████████ did not feel anything different ought to have been done, and I formed the view that even if some measures were felt to be necessary to assist service users such as Steven, these were not necessarily going to be implemented with the speed which may be necessary to minimise potential risks .
• I found ████████ stance surprising, and I determined that there had been an under – appreciation of the level of risk. It creates an obvious risk to other service users when vulnerable people such as Steven are not appropriately assessed in terms of potential risks. It means necessary preventative measures may not be put in place , and that their lives are at risk as a consequence.
• The approach of a relatively senior member of the care staff can, of course, have an impact upon the approach adopted by other personnel and particularly regarding more junior staff.
” Source location Steven Duquemin · Prevention of Future Deaths report
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 appropriately assess and record choking risks for vulnerable service users
Wider context from the report “• Entries in care records were inconsistent, some indicating Steven was not at risk of choking when he clearly was at such risk , and indeed one member of staff gave credible evidence that she had on one occasion have to use skills learned at some recent training to assist Steven after he overfilled his mouth with food.
• My concern is quite straight-forward. I received evidence from a Service Manager. In my judgement, in the face of quite overwhelming evidence to the contrary – including a clear medical cause of death reported by the Pathologist - ████████ continued to maintain that Steven had not been at risk of choking , and appeared to stand by entries in care records to the extent they indicated he had not been at risk of choking.
• As I indicated at the conclusion of the inquest, it appeared to me that ████████ did not feel anything different ought to have been done, and I formed the view that even if some measures were felt to be necessary to assist service users such as Steven, these were not necessarily going to be implemented with the speed which may be necessary to minimise potential risks.
• I found ████████ stance surprising, and I determined that there had been an under – appreciation of the level of risk . It creates an obvious risk to other service users when vulnerable people such as Steven are not appropriately assessed in terms of potential risks . It means necessary preventative measures may not be put in place, and that their lives are at risk as a consequence.
• The approach of a relatively senior member of the care staff can, of course, have an impact upon the approach adopted by other personnel and particularly regarding more junior staff.
” Source location Steven Duquemin · Prevention of Future Deaths report
Open source report
4 Nov 2022 John Fallon · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Unavailability of suction machines in care homes for staff management of choking View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
John Fallon · 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
John Fallon, who had dementia and was resident at Downshaw Lodge Care Home, choked on partially chewed meat while eating lunch without his dentures on 13 March 2022. The concerns included the lack of routine SALT assessments and diet changes when residents eat without dentures, delays in replacing or updating dentures due to limited dental services, and the absence of routinely available suction machines in care homes.
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 Unavailability of suction machines in care homes for staff management of choking
Wider context from the report “3. NWAS used a suction machine to clear the airway on their arrival. The inquest heard evidence that these are not routinely in place at care homes and so if a resident is choking food cannot be suctioned out by staff .
” Source location John Fallon · Prevention of Future Deaths report
Open source report
12 Aug 2022 Helen Ruth BURNELL · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 1
Failure of staff to adequately recognise choking risks View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Helen Ruth BURNELL · 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
Helen Ruth Burnell choked on a sandwich while eating dinner and suffered a fatal hypoxic brain injury after respiratory and cardiac arrest. The report raised concerns that staff had not adequately recognised choking risks and that improved training was needed to support adherence to meal-time recommendations.
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 of staff to adequately recognise choking risks
Wider context from the report “1) I identified that better training should be given to staff in respect of choking risks. Choking is a serious health and safety risk and concern for adults with autism and those with learning disabilities. The risk of choking does not appear to have been adequately recognised by staff.
(2) Improved training of staff, care givers and their respective managers may have the potential to increase adherence to meal time recommendations and lessen the risk of choking.
” Source location Helen Ruth BURNELL · Prevention of Future Deaths report
Open source report
16 Jun 2022 James Joseph MANNING · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Absence of choking-related red flags in tonsillectomy guidance View source
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
James Joseph MANNING · 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
James Joseph Manning, aged two, choked on a piece of sausage at Butlins, Bognor Regis, on 6 June 2018, suffered a cardiac arrest and hypoxic ischaemic brain injury, and died in hospital on 20 June 2018. The concerns included delays and weaknesses in healthcare referral, follow-up and information-sharing systems, and shortcomings in the management of health and safety, incident reporting, first-aid provision and emergency procedures at Bourne Leisure sites.
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 Absence of choking-related red flags in tonsillectomy guidance
Wider context from the report “a) I heard expert evidence that GPs and general hospital doctors would benefit from national guidance to ensure that greater consistency is achieved when referring children for tonsillectomy and similar treatment. In addition, both GP and hospital doctors gave evidence that raised a concern regarding:
i. whether additional guidance may be appropriate to help doctors decide which cases need an urgent referral to hospital or tertiary care; and
ii. a system of red flags – for example including choking in the ENT UK Commissioning Guide for Tonsillectomy (2016). Experts and witnesses confirmed that choking is not mentioned in the current Guide .
” Source location James Joseph MANNING · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.