Recurring concern

Inadequate food-hygiene controls in care settings

First to latest report 1 Oct 2018 — 12 Aug 2025

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
10

What this concern includes

Includes failures of controls specifically dedicated to food hygiene in care settings, including separation of cleaning from food-and-water handling duties, suitability checks for food brought into the setting, safe preparation or serving temperatures, and comparable contamination-prevention controls.

What is not included
  • Excludes general nutrition, hydration, meal provision or dietary-choice deficiencies where food hygiene is not the unsafe condition.
  • Excludes generic cleaning, staffing, training or role-clarity deficiencies unless they directly impair a food-hygiene control.
  • Excludes food-allergy management, dysphagia precautions and clinical nutritional support unless the assertion specifically concerns food hygiene or contamination.
  • Excludes isolated food-related discomfort or poor service where no food-hygiene deficiency is identified.

Reports and published responses 4 reports

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

  1. Gloucestershire

    AI-generated summary

    Margaret Taylor · 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

    Margaret Taylor, who had dementia, dysphagia and a severe risk of choking, died after choking on chicken brought to her care home on 8 November 2024. Concerns included her removal from a soft-food diet without a documented rationale or further SALT assessment, and staff not checking food brought in by her husband for suitability in accordance with the home's policy.

    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 check food brought into the home for suitability

    Wider context from the report

    “- There was no documented rationale, or further SALT assessment, before Maggie was removed from the soft food diet - Food brought in by Maggie’s husband was not checked for suitability by the staff at the home I am concerned that if important decisions are being taken without proper assessment by the SALT team, and the rationale for these decisions is not being properly documented, and if food is not being check in accordance with policy, then there is a risk of future deaths. ”

    Source location

    Margaret Taylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Cristofaro PRIOLO · 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

    Cristofaro Priolo, an 80-year-old man with progressive Alzheimer’s dementia who lived in a nursing home, choked on cauliflower cheese on 25 November 2020 and died. The report identifies concerns that his food was not prepared or fed in accordance with his assessed needs, and that staff failed to provide appropriate first aid, recognise cardiac arrest, and attempt effective 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 prepare food safely for people at risk of choking

    Wider context from the report

    “A BUPA internal investigation has already taken place and identified some learning points. However, there are matters outstanding around training and audit. Obviously, the cauliflower for Mr Priolo should have been prepared properly for him by the catering staff, but quite apart from that, Mr Priolo’s carers were never assessed when they were feeding him. Whilst the carer who was feeding him when he choked knew that he needed small, soft mouthfuls that he should be allowed to swallow completely before offering the next, that is not what happened. He was fed a large quantity of cauliflower cheese, it seems relatively quickly, that was undercooked to the point of being almost raw, making it much too hard for him to swallow safely. Staff, including qualified nursing staff, then failed to give appropriate first aid. Even 18 months after the event when they were giving evidence in court this week – the inquest had been delayed to allow a police investigation – some staff were unable to describe the correct treatment for choking. Most significantly, nursing staff failed to recognise that Mr Priolo had suffered a cardiac arrest. They then failed to attempt CPR. After the arrival of paramedics, one member of nursing staff did attempt to give chest compressions, but these were ineffective. That is likely to be the result of panic and distress. These are common feelings in an emergency situation, but the risk of them overwhelming resuscitation efforts may be reduced by frequent appropriate training. ”

    Source location

    Cristofaro PRIOLO · 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

    Strengthen and embed the Highgate Mealtime Champion role to oversee mealtime support and compliance with dietary requirements.

    Verbatim wording from the response

    “• The role of “Mealtime Champion” was strengthened in the Highgate. The person fulfilling this role in the Highgate assists with the mealtime experience of residents and ensures that any dietary”

    Source location

    Response from BUPA Care Services
    Page 1 · response
    Published 12 May 2022

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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

    Reinforce and strengthen the Mealtime Champion role across the care-home portfolio.

    Verbatim wording from the response

    “The role of Mealtime Champion generally is included and defined within our Mealtime Experience document, which applies to all our care homes. As a general point, this role will be reinforced and strengthened throughout our portfolio. The Mealtime Champion is defined in the document as being someone who is in charge of coordinating the mealtime experience for residents, and actively supervises the meal service. They need to ensure that residents receive the appropriate levels of nutrition, hydration and supervision, to avoid instances such as choking.”

    Source location

    Response from BUPA Care Services
    Page 2 · response
    Published 12 May 2022

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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

    Implement UK-wide kitchen quality assurance checks for food temperature, thorough cooking and required consistency before food leaves the kitchen.

    Verbatim wording from the response

    “1. Bupa will implement a process to ensure food is quality assured prior to leaving the kitchen. This will be clearly described in our HACCP (Hazard Analysis and Critical Control Point) policy and documented next to the temperature checks within our standard paperwork. This new process will ensure that all food leaves the kitchen, a) at the right temperature and b) cooked thoroughly or the correct consistency. This would address and identify any repeat of undercooked food leaving the kitchen. This process will not be unique to the Highgate, it will be adopted UK wide across our portfolio.”

    Source location

    Response from BUPA Care Services
    Page 2 · response
    Published 12 May 2022

    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

    Review HACCP, nutrition, mealtime, IDDSI and induction materials to align policies and training with safe dietary assistance.

    Verbatim wording from the response

    “2. A review of the HACCP policy, Nutrition and Weight Management policy, Mealtime Experience Standards, and associated training such as the International Dysphagia Diet Standardisation Initiative (IDDSI) will take place to ensure the actions described in this response are reflected in policy and training. This will include a review of induction material (Nutrition and Hydration) to ensure staff are taught how to assist residents with dietary intake in a safe way applicable to their needs.”

    Source location

    Response from BUPA Care Services
    Page 2 · response
    Published 12 May 2022

    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

    Develop and roll out role-specific IDDSI descriptor videos across the organisation, updating the Mealtime Experience document afterwards.

    Verbatim wording from the response

    “3. Bupa, in collaboration with Robot Coupe, will develop a suite of short videos, targeted to film in July 2022, on each of the IDDSI descriptors levels. This should be completed by the end of August 2022 and will be made available across the organisation and rolled out to employees subject to their roles. The Mealtime Experience document (referred to earlier in this response) will be reviewed in line with the IDDSI work we are planning and will be updated once the videos have been produced.”

    Source location

    Response from BUPA Care Services
    Page 3 · response
    Published 12 May 2022

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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

    Enforce the Resident Mealtime Form process and maintain its monthly or needs-based review for resident-specific dietary information.

    Verbatim wording from the response

    “4. The Resident Mealtime Form (completed by the nursing and care team at the point of a resident’s admission and used by the catering team) will be enforced. This will ensure that the existing process is operating effectively. This form is designed to capture resident specific information such as allergies, modified diet requirements or specific cutlery required. The form is reviewed monthly or more frequently as required. At Highgate, a copy of this form is kept within the Home’s SaLT folders, including the SaLT folder kept in the kitchen. The SaLT folder includes for each of the Home’s residents: dietary information, the Resident Mealtime Form, eating/drinking protocols, IDDSI recommendations for residents, recommendations/advice from SaLT, the IDDSI framework and guidance on this, and blank SaLT referral forms.”

    Source location

    Response from BUPA Care Services
    Page 3 · response
    Published 12 May 2022

    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

    Communicate lessons learned and changed catering processes to Chef Managers and catering teams across the business.

    Verbatim wording from the response

    “7. The Director of Hotel Services and Customer First will communicate with all Chef Managers and their teams and relay the lessons learned. This will ensure there is awareness across the business of what happened at The Highgate, how we can learn from this and what we have changed as a result of it. Our catering teams can then implement the new processes. We are also exploring ways of providing face to face training for our catering teams on the requirements of IDDSI and are making available frozen IDDSI accredited meals from our suppliers so that our services can access appropriately modified meals as a contingency.”

    Source location

    Response from BUPA Care Services
    Page 3 · response
    Published 12 May 2022

    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

    Make frozen IDDSI-accredited meals available from suppliers as a contingency for appropriately modified meals.

    Verbatim wording from the response

    “7. The Director of Hotel Services and Customer First will communicate with all Chef Managers and their teams and relay the lessons learned. This will ensure there is awareness across the business of what happened at The Highgate, how we can learn from this and what we have changed as a result of it. Our catering teams can then implement the new processes. We are also exploring ways of providing face to face training for our catering teams on the requirements of IDDSI and are making available frozen IDDSI accredited meals from our suppliers so that our services can access appropriately modified meals as a contingency.”

    Source location

    Response from BUPA Care Services
    Page 3 · response
    Published 12 May 2022

    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

    Add safe-feeding materials and a competency check to the Nutrition and Hydration training module.

    Verbatim wording from the response

    “8. We have asked for additional materials and a competency check to be added to the current Nutrition and Hydration training module and we will work with our Learning and Development team to ensure this happens.”

    Source location

    Response from BUPA Care Services
    Page 3 · response
    Published 12 May 2022

    Open published response

  3. Manchester South

    AI-generated summary

    Barry Wayne Preston · 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

    Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.

    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 ensure food is served at a safe temperature

    Wider context from the report

    “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort. ”

    Source location

    Barry Wayne Preston · Prevention of Future Deaths report
    Page 3 · 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

    Trafford Council was responsible for a safeguarding investigation if the hospital referred the burn incident under section 42.

    Verbatim wording from the response

    “Whilst the Manchester Foundation Trust completed its own internal root cause analysis it is not clear whether they referred this incident to Trafford Council for a section 42 Safeguarding Investigation under the Care Act 2014. As the host authority, Trafford Council would have been responsible for undertaking the investigation had it been referred to them by the hospital but they would have notified Bolton Council if this was the case as Bolton was the authority where Mr Preston was ordinarily resident.”

    Source location

    2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
    Page 3 · response
    Published 9 June 2020

    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

    Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.

    Verbatim wording from the response

    “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.”

    Source location

    2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 1 · response
    Published 9 June 2020

    Open published response

  4. Brighton and Hove

    AI-generated summary

    Mrs. Joan Catherine BLABER · 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

    The report concerns the death of Mrs. Joan Catherine BLABER, with the circumstances referred to in the Record of Inquest. The principal concerns included failures to comply with COSHH requirements, inadequate training and supervision, confusion over staff roles, poor communication of practices, and failures to report and learn from dangerous or near-miss events.

    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 maintain separation of cleaner and food-and-water handling roles

    Wider context from the report

    “(3) Confusion in roles. Mixing the roles of the cleaners with those members of staff who should only be dealing with food and water. ”

    Source location

    Mrs. Joan Catherine BLABER · 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

    Separate Host, Catering Assistant and Housekeeper roles, with dedicated Catering Assistants, differentiated uniforms and a Trust-wide rollout.

    Verbatim wording from the response

    “I am pleased to say the roles of Hosts and Housekeepers has been split and clarified as recommended by you at the inquest. We now have dedicated Catering Assistants who have no cleaning duties outside the kitchen. Housekeepers are now tasked with cleaning duties and do not deal with patients’ food or water. These new clearer roles have started in the Barry Building, Sussex Eye Hospital and the Nursery and there is a roll out programme in progress so the whole of the Trust will be incorporated by the end of March 2019. To”

    Source location

    Response from Brighton and Sussex University Hospitals
    Page 1 · response
    Published 23 February 2024

    Open published response

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

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Data last updated 7 September 2026