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.
Inner North London
Concerns raised2
Failure to prepare food safely for people at risk of choking
Failure to provide appropriate first aid for choking
This report raised 5 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.11
Action
Strengthen and embed the Highgate Mealtime Champion role to oversee mealtime support and compliance with dietary requirements.
Stated by BupaStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
Action
Reinforce and strengthen the Mealtime Champion role across the care-home portfolio.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Implement UK-wide kitchen quality assurance checks for food temperature, thorough cooking and required consistency before food leaves the kitchen.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Review HACCP, nutrition, mealtime, IDDSI and induction materials to align policies and training with safe dietary assistance.
Stated by BupaStated in progressThe respondent said that this action was in progress when they made their response on 12 May 2022.
Action
Develop and roll out role-specific IDDSI descriptor videos across the organisation, updating the Mealtime Experience document afterwards.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Enforce the Resident Mealtime Form process and maintain its monthly or needs-based review for resident-specific dietary information.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Communicate lessons learned and changed catering processes to Chef Managers and catering teams across the business.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Make frozen IDDSI-accredited meals available from suppliers as a contingency for appropriately modified meals.
Stated by BupaStated in progressThe respondent said that this action was in progress when they made their response on 12 May 2022.
Action
Add safe-feeding materials and a competency check to the Nutrition and Hydration training module.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Action
Provide and competency-assess Basic Life Support and DNACPR training, including practical choking and CPR assessment.
Stated by BupaStated completedThe respondent said that this action was complete when they made their response on 12 May 2022.
Action
Retrain remaining Highgate staff and ensure they are competent and confident to manage future choking, cardiac arrest and CPR incidents.
Stated by BupaStated plannedThe respondent said that this action was planned when they made their response on 12 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing evidence indicates Highgate BLS delegates passed competency assessments, disputing that training competence was absent.
Stated by BupaDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Insufficient police officer awareness of plastic bag and choking risks
This report raised 9 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.
North Wales (East and Central)
Concerns raised3
Failure of staff to demonstrate understanding of safe food and fluid care and choking-risk management
Insufficient staff training in first aid and assisting residents at risk of choking
Insufficient staff training in selecting and preparing food and fluids for residents at risk of choking
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.7
Action
Train current staff in basic dysphagia awareness.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Train new staff on SALT IDDS dysphagia procedures at the scheduled training session.
Stated by Coed DuonStated plannedThe respondent said that this action was planned when they made their response on 14 August 2019.
Action
Establish two trained dysphagia champions to support staff training.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Teach new staff safe care for residents at choking risk and prohibit assistance before completing this training.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Provide trained mealtime staff in the dining room to oversee dysphagia-trained staff assisting residents at choking risk.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Establish at least one qualified first aider on duty at all times.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Action
Maintain resident-specific diet and fluid consistency files, with staff acknowledgement of changes.
Stated by Coed DuonStated completedThe respondent said that this action was complete when they made their response on 14 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
There was no evidence that the aspirated food had not been prepared to a safe consistency.
Stated by Coed DuonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Bedfordshire and Luton
Concerns raised1
Lack of knowledge of choking risks during arrest or detention
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.3
Action
Provide annual first-aid training, including choking management, to officers, special constables, detention officers and Police Community Support Officers.
Stated by Bedfordshire PoliceStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
Action
Train officers and students to use choking training aids and demonstrate front-position thrusts when rescuers cannot encircle a casualty.
Stated by Bedfordshire PoliceStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
Action
Give officers and custody staff instructions for managing detainees who place items in their mouths, swallow items or begin choking, including ambulance escalation and emergency life support.
Stated by Bedfordshire PoliceStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Regular choking training complies with IOPC recommendations and meets College of Policing standards.
Stated by Bedfordshire PoliceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Berkshire
Concerns raised1
Lack of training for bank staff in caring for patients at risk of choking
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of care assistant understanding and systems for escalating choking episodes to SALT
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.
Inner North London
Concerns raised1
Choking without classic visible signs
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.
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.2
Action
Provide recruit and three-yearly refresher training on recognising and treating choking, including cases without classic signs.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 14 August 2018.
Action
Train officers to conduct thorough breathing checks, monitor breathing, open airways and commence CPR when breathing is abnormal or uncertain.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 14 August 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing MPS Emergency Life Support training addresses recognition of concealed medical emergencies, choking, abnormal breathing and appropriate first-aid responses.
Stated by Metropolitan Police ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
London (East)
Concerns raised1
Failure to maintain robust systems for protecting patients at risk of choking, including checking food
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.1
Action
Implement revised care policies and processes across the group’s homes to improve resident safety.
Stated by Aspray House LtdStated completedThe respondent said that this action was complete when they made their response on 1 July 2018.
Nottinghamshire
Concerns raised2
Inadequate and disorganised choking risk assessment record keeping
Lack of staff knowledge of residents at high risk of choking and supervision needs
This report raised 10 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.7
Action
Complete swallowing risk assessments with independent validation and Care Manager sign-off of updates.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Action
Rewrite residents’ care plans to specify detailed individual care requirements.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Action
Introduce dining registers and quick-reference guides for managing specialist diets, with formal review and update governance.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Action
Implement daily ‘Resident of the day’ care-plan reviews and report changing needs through the clinical risk register.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Action
Share residents’ SALT fluid and diet requirements with catering, housekeeping, care and nursing staff.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Action
Commission a three-day face-to-face dysphagia course for the home’s staff from an external expert provider.
Stated by Hc-One LimitedStated plannedThe respondent said that this action was planned when they made their response on 17 June 2018.
Action
Provide supervision to all home colleagues, identify knowledge gaps and source role-relevant learning.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Birmingham and Solihull
Concerns raised1
Lack of staff first aid training and choking-sign recognition
This report raised 5 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
The registered care provider is responsible for ensuring sufficient, qualified, competent and appropriately trained staff are deployed.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
