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.
Surrey
Concerns raised1
Insufficient staff knowledge and understanding of the BUPA policy on 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Failure to train care staff in CPR and choking procedures
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.4
Action
Implement an additional action plan and timetable responding to the inquest findings.
Stated by Avery Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Continue embedding all organisational policies and procedures at Aran Court.
Stated by Avery Healthcare GroupStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
Action
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Action
Maintain the Care Certificate as an induction and development standard covering safe, effective care for health and social care workers.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Emergency first aid and basic life-support training is considered an appropriate level of training for staff responding to choking and CPR situations.
Stated by Avery Healthcare GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing emergency first-aid training, shift reminders and staff competence checks were considered sufficient to address emergency response concerns.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Care Certificate induction standards and workplace competence assessment were considered sufficient to ensure HCAs had necessary knowledge and skills.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Care homes are responsible for providing and maintaining staff training, including emergency telephone, CPR and choking procedures.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
London (East)
Concerns raised1
Care plans failing to specify swallowing-risk management measures
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.2
Position
The agency disputes being informed of the SALT assessment, choking risk, or recommendations requiring food preparation and meal supervision.
Stated by John Stanley’s Care AgencyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The agency says it could not supervise eating within the 30-minute visit while completing the existing personal-care tasks without additional allocated time.
Stated by John Stanley’s Care AgencyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Absence of choking-risk warnings on packets of raw jelly
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.1
Action
Forward the report to relevant food manufacturing and retail trade bodies for information and consideration regarding warnings about raw jelly cube risks.
Stated by Food Standards AgencyStated plannedThe respondent said that this action was planned when they made their response on 29 September 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Warnings on food-product packaging are outside Ofsted’s remit.
Stated by OfstedOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Food Standards Agency will respond about possible further action on warnings for raw jelly packaging.
Stated by OfstedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
There is no specific legal requirement to require warnings on packaging or loose-food point-of-sale notices; manufacturers and retailers may act voluntarily.
Stated by Food Standards AgencyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Lack of up-to-date first aid certification and choking-response knowledge among staff
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.
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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.
