Recurring concern

Unsafe implementation of choking-risk prevention measures

First to latest report 30 Jul 2014 — 19 Feb 2026

Reports that mention this concern: 25
Times this concern has been raised: 31
Stated actions linked to this concern: 55

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.

What is 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.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

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

Reports and published responses 25 reports

See individual reports that have raised this concern, and the actions taken in response

25 Jan2017
Surrey
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Geraldine Butterfield · 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

Geraldine Butterfield died on 25 July 2015 after choking on food while eating lunch at a nursing home; the cause of death was recorded as asphyxia due to food inhalation. Concerns were raised that some nursing staff did not sufficiently understand or implement the choking policy, and did not sufficiently understand when potentially life-saving treatment should be provided to a person with a DNAR order.

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
Insufficient staff knowledge and understanding of the BUPA policy on choking
Wider context from the report
“Having heard evidence from a number of members of the nursing staff, I am concerned that not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking, so as to be able to effectively implement it in the future. I am also concerned that not all staff members have a sufficient understanding of when potentially life-saving treatment should be provided to individuals in respect of whom a DNAR order is in place. - Not all staff members have a sufficient knowledge and understanding of the BUPA policy on choking so as to be able to effectively implement it in the future. - Not all staff members have a sufficient understanding of when potentially life-saving treatment should be provided to individuals in respect of whom a DNAR order is in place. Consideration should be given to whether any steps, including further training, can be taken to address the above concerns. ”
Source location
Geraldine Butterfield · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Oct2016
Birmingham and Solihull
Concerns raised1
1. 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.
Linked responses

Avery Healthcare Group
Care Quality Commission
Department of Health and Social Care
NHS England
Stated actions 4
1. Avery Healthcare Group
  Implement an additional action plan and timetable responding to the inquest findings.
2. Avery Healthcare Group
  Continue embedding all organisational policies and procedures at Aran Court.
3. Care Quality Commission
  Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.
1. Department of Health and Social Care
  Maintain the Care Certificate as an induction and development standard covering safe, effective care for health and social care workers.
Respondent positions 4
1. Avery Healthcare Group
  Emergency first aid and basic life-support training is considered an appropriate level of training for staff responding to choking and CPR situations.
  Existing arrangements considered sufficient
1. Care Quality Commission
  Existing emergency first-aid training, shift reminders and staff competence checks were considered sufficient to address emergency response concerns.
  Existing arrangements considered sufficient
2. Care Quality Commission
  Care Certificate induction standards and workplace competence assessment were considered sufficient to ensure HCAs had necessary knowledge and skills.
  Existing arrangements considered sufficient
3. NHS England
  Care homes are responsible for providing and maintaining staff training, including emergency telephone, CPR and choking procedures.
  Redirects responsibility
AI-generated summary

Robert Arthur Davidson · 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

Robert Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating CPR.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to train care staff in CPR and choking procedures
Wider context from the report
“1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows: • Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient. • When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations. ”
Source location
Robert Arthur Davidson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement an additional action plan and timetable responding to the inquest findings.

Verbatim wording from the response
“Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these processes in place and where systems or processes were in situ they were often substandard. It remains an ongoing process to fully embed all of Avery’s policies and procedures and in light of the inquests findings an additional action plan and timetable for action has been implemented.”

Source location
2016-0363-Response-by-Avery
Page 2 · response
Published 26 February 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue embedding all organisational policies and procedures at Aran Court.

Verbatim wording from the response
“Unfortunately, whilst under the Restful Homes Group tenure, Aran Court had very few of these processes in place and where systems or processes were in situ they were often substandard. It remains an ongoing process to fully embed all of Avery’s policies and procedures and in light of the inquests findings an additional action plan and timetable for action has been implemented.”

Source location
2016-0363-Response-by-Avery
Page 2 · response
Published 26 February 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Inspect care homes’ emergency response, staff training, induction, and transfer-risk arrangements, including follow-up checks against the reported concerns.

Verbatim wording from the response
“During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid. Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious. The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities.”

Source location
2016-0363-Response-by-Care-Quality-Commission
Page 2 · response
Published 26 February 2017
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain the Care Certificate as an induction and development standard covering safe, effective care for health and social care workers.

Verbatim wording from the response
“In April 2015, the Government introduced the Care Certificate (as recommended by Camilla Cavendish in her July 2013 review), which is helping to ensure that support workers and their employers can deliver a consistently high quality standard of safe, effective and compassionate care. It includes 15 standards and outcomes that health and social care workers – in hospitals, care homes and people’s own homes – should know and be able to deliver in their daily work. Regarded as ‘best practice’ for the induction of new health and care assistants, it is also offering existing staff an opportunity to refresh or improve their knowledge.”

Source location
2016-0363-Response-by-Department-of-Health
Page 1 · response
Published 26 February 2017
Open published response
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 first aid and basic life-support training is considered an appropriate level of training for staff responding to choking and CPR situations.

Verbatim wording from the response
“As a provider Avery Healthcare does have appropriate systems and documentation in situ to address each of the above points.”

Source location
2016-0363-Response-by-Avery
Page 1 · response
Published 26 February 2017
Open published response
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
Existing emergency first-aid training, shift reminders and staff competence checks were considered sufficient to address emergency response concerns.

Verbatim wording from the response
“During the course of the CQC focused inspection of Aran Court Care Centre on 09 March 2016, we found systems in place to ensure that nurses had training in emergency first aid. Emergency First Aid at work training provides delegates with an extensive first aid skill set so that they can identify incidents and manage them appropriately, whether the patient is conscious or unconscious. The course is designed to include first aid priorities, managing incidents, basic life support (CPR), unconsciousness, control of bleeding, burns and scolds, recording and reporting First Aid Priorities.”

Source location
2016-0363-Response-by-Care-Quality-Commission
Page 2 · response
Published 26 February 2017
Open published response
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
Care Certificate induction standards and workplace competence assessment were considered sufficient to ensure HCAs had necessary knowledge and skills.

Verbatim wording from the response
“The Care Certificate was developed jointly by Skills for Care, Health Education England and Skills for Health, and introduced on 01 April 2015. These Care Certificate standards apply across both social care and health, and link to the national occupational standards. The Care Certificate is designed for new HCA staff, it also offers opportunities for existing staff to refresh or improve their knowledge. The new standards encapsulated in the Care Certificate should ensure that the health and social care workers have the required values, behaviours, competences and skills to provide high quality, compassionate care.”

Source location
2016-0363-Response-by-Care-Quality-Commission
Page 3 · response
Published 26 February 2017
Open published response
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
Care homes are responsible for providing and maintaining staff training, including emergency telephone, CPR and choking procedures.

Verbatim wording from the response
“Care organisations, including homes such as Aran Court Care Centre, are responsible for the induction and training of their staff. This should include the use of the telephone in emergency situations. Basic CPR training is a minimal expectation of those working in care settings. It is the responsibility of the care home to provide this training and ensuring that staff maintains their competence through regular updates. It may be necessary for the care home to access training in the NHS to meet these requirements.”

Source location
2016-0363-Response-by-NHS-England
Page 1 · response
Published 26 February 2017
Open published response
20 Feb2015
London (East)
Concerns raised1
1. 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.
Linked response

John Stanley’s Care Agency
Respondent positions 2
1. John Stanley’s Care Agency
  The agency disputes being informed of the SALT assessment, choking risk, or recommendations requiring food preparation and meal supervision.
  Disputes the concern
1. John Stanley’s Care Agency
  The agency says it could not supervise eating within the 30-minute visit while completing the existing personal-care tasks without additional allocated time.
  Unable to act
AI-generated summary

Michael Joseph Lyons · 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

Michael Joseph Lyons had Parkinson’s disease with significant difficulties in balance, speech and swallowing. On 23 September 2014, while being cared for at home, he choked on cheese on toast after it was not cut into small pieces and he was left eating unsupervised, causing his death. Concerns included the absence of an adequate care plan addressing the known choking risk, including food preparation and supervision, and the failure to establish and implement the speech and language therapist’s 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
Care plans failing to specify swallowing-risk management measures
Wider context from the report
“(1) The Care Agency were aware of the swallowing difficulties experienced by Mr Lyons and they had been informed of a SALT assessment having taken place in June 2014. (2) There was no evidence that the Care Agency had made any attempt to determine the outcome of the SALT assessment and to put into place steps to protect Mr Lyons from the risk of choking. (3) Some carers were aware of the need for food to be cut into small pieces. The carer who attended on the 23 September confirmed that she was not aware that food needed to be cut up. (4) The care plan did not provide a management plan to protect Mr Lyons from the risk of choking. The care plan did not specify that food should be cut up and did not confirm that Mr Lyons should be supervised. (5) The care plan was dated 10 September 2014. The information from the SALT was available at that time and the author of the care plan should have taken steps to ensure that the care plan reflected the recommendations from the assessment. ”
Source location
Michael Joseph Lyons · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The agency disputes being informed of the SALT assessment, choking risk, or recommendations requiring food preparation and meal supervision.

Verbatim wording from the response
“We were aware that Mr Lyons had difficulty with swallowing as a consequence of his sister ████████ informing us during our risk assessment. Our paperwork states that ‘no other health/social care professionals are involved in Mr Lyons’ care at this time. There is no information documented that we have been informed that a SALT assessment had taken place.”

Source location
2015-0067-Response-by-John-Stanley-Care-Agency
Page 3 · response
Published 20 February 2015
Open published response
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
The agency says it could not supervise eating within the 30-minute visit while completing the existing personal-care tasks without additional allocated time.

Verbatim wording from the response
“The increase for the morning call would have been required, as it is impossible to carry out all the personal care tasks already stipulated on the care plan and supervise Mr Lyons’ eating within the 30 minutes allocated by Social Services. We have no paperwork stipulating that Mr Lyons was at risk of choking and, therefore, needed to be supervised for all meals.”

Source location
2015-0067-Response-by-John-Stanley-Care-Agency
Page 2 · response
Published 20 February 2015
Open published response
29 Sep2014
Inner West London
Concerns raised1
1. 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.
Linked responses

Food Standards Agency
Ofsted
Stated actions 1
1. Food Standards Agency
  Forward the report to relevant food manufacturing and retail trade bodies for information and consideration regarding warnings about raw jelly cube risks.
Respondent positions 3
1. Ofsted
  Warnings on food-product packaging are outside Ofsted’s remit.
  Outside remit
1. Ofsted
  The Food Standards Agency will respond about possible further action on warnings for raw jelly packaging.
  Redirects responsibility
2. Food Standards Agency
  There is no specific legal requirement to require warnings on packaging or loose-food point-of-sale notices; manufacturers and retailers may act voluntarily.
  Unable to act
AI-generated summary

Tiya Chetan Chauhan · 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

Tiya Chetan Chauhan died on 24 August 2012 at St George’s Hospital after inhaling a cube of raw jelly that obstructed her airway during a sensory tray activity at a nursery. The report identified concerns about the choking risk of raw jelly cubes, inadequate supervision, insufficient risk assessment, and the absence of warnings on packets of raw jelly.

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-risk warnings on packets of raw jelly
Wider context from the report
“(2) That packets of raw jelly do not contain a warning that cubes of jelly present a choking risk to children. ”
Source location
Tiya Chetan Chauhan · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Forward the report to relevant food manufacturing and retail trade bodies for information and consideration regarding warnings about raw jelly cube risks.

Verbatim wording from the response
“In relation to your concerns over the lack of warning about the issue on packaging, the FSA will forward a copy of your report to relevant industry manufacturing and retail trade bodies, for their information and consideration. I can confirm that there is no specific legal requirement (in what is an area of law closely harmonised at EU level) for such food to contain a warning on the label or on a point of sale notice if sold loose. However, this is something that a particular manufacturer or retailer”

Source location
2014-0575-Response-by-Food-Standards-Agency
Page 1 · response
Published 29 September 2014
Open published response
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
Warnings on food-product packaging are outside Ofsted’s remit.

Verbatim wording from the response
“The inclusion of warnings on the packaging of food items and products is not a matter for Ofsted. We have discussed this concern with the FSA and have agreed that they will respond to you on the possibility for further action.”

Source location
2014-0575-Response-by-Ofsted
Page 2 · response
Published 29 September 2014
Open published response
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
The Food Standards Agency will respond about possible further action on warnings for raw jelly packaging.

Verbatim wording from the response
“The inclusion of warnings on the packaging of food items and products is not a matter for Ofsted. We have discussed this concern with the FSA and have agreed that they will respond to you on the possibility for further action.”

Source location
2014-0575-Response-by-Ofsted
Page 2 · response
Published 29 September 2014
Open published response
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
There is no specific legal requirement to require warnings on packaging or loose-food point-of-sale notices; manufacturers and retailers may act voluntarily.

Verbatim wording from the response
“In relation to your concerns over the lack of warning about the issue on packaging, the FSA will forward a copy of your report to relevant industry manufacturing and retail trade bodies, for their information and consideration. I can confirm that there is no specific legal requirement (in what is an area of law closely harmonised at EU level) for such food to contain a warning on the label or on a point of sale notice if sold loose. However, this is something that a particular manufacturer or retailer”

Source location
2014-0575-Response-by-Food-Standards-Agency
Page 1 · response
Published 29 September 2014
Open published response
30 Jul2014
Manchester South
Concerns raised1
1. 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Edna Smither · 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

Edna Smither choked on sausage while being fed lunch at Peel Moat Care Home on 25 April 2013 and died later that day in hospital. Concerns included limited up-to-date first-aid certification, a delay caused by a locked door, panic and a lack of calm leadership or training, and failures to report incidents under RIDDOR without delay.

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
Lack of up-to-date first aid certification and choking-response knowledge among staff
Wider context from the report
“1. It transpired during the course of the hearing that only one (comparatively junior) member of staff present on the day of the incident and death, had a First Aid certificate which was ‘in date’. Whilst I recognise that there is no legal requirement for this, none the less I feel it would be very helpful for all staff to have up-to-date certification, so that they would know when to, and how to, carry out abdominal thrusts to dislodge food boluses etc. ”
Source location
Edna Smither · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Insufficient staff knowledge and understanding of the BUPA policy on choking

Concerns raised1

Failure to train care staff in CPR and choking procedures

Linked responses

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Concerns raised1

Care plans failing to specify swallowing-risk management measures

Linked response

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Absence of choking-risk warnings on packets of raw jelly

Linked responses

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Lack of up-to-date first aid certification and choking-response knowledge among staff

Stated actions 4

Respondent positions 4

Respondent positions 2

Stated actions 1

Respondent positions 3