Recurring concern

Inadequate food-hygiene controls in care settings

Get email alerts

Request correction

First reported 1 Oct 2018•Latest report 12 Aug 2025

Definition

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.

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: 4
Individual concerns: 4
Date range: 2018–2025
Stated actions: 10

Reports 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.

Bolton Borough Council1

Bupa Care Homes (GL) Limited1

Department of Health and Social Care1

Greater Manchester Mental Health NHS Foundation Trust1

Oak Tree Mews1

Royal Bolton Hospital1

The Highgate Care Home1

University Hospitals Sussex NHS Foundation Trust1

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.

12 Aug2025
Gloucestershire
Concerns raised1
1. Failure to check food brought into the home for suitability
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
11 May2022
Inner North London
Concerns raised1
1. Failure to prepare food safely for people at risk of choking
This report raised 6 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 9
1. Action
  Strengthen and embed the Highgate Mealtime Champion role to oversee mealtime support and compliance with dietary requirements.
  Stated by BupaStated completed
2. Action
  Reinforce and strengthen the Mealtime Champion role across the care-home portfolio.
  Stated by BupaStated planned
3. Action
  Implement UK-wide kitchen quality assurance checks for food temperature, thorough cooking and required consistency before food leaves the kitchen.
  Stated by BupaStated planned
1. Action
  Review HACCP, nutrition, mealtime, IDDSI and induction materials to align policies and training with safe dietary assistance.
  Stated by BupaStated in progress
2. Action
  Develop and roll out role-specific IDDSI descriptor videos across the organisation, updating the Mealtime Experience document afterwards.
  Stated by BupaStated planned
3. Action
  Enforce the Resident Mealtime Form process and maintain its monthly or needs-based review for resident-specific dietary information.
  Stated by BupaStated planned
4. Action
  Communicate lessons learned and changed catering processes to Chef Managers and catering teams across the business.
  Stated by BupaStated planned
5. Action
  Make frozen IDDSI-accredited meals available from suppliers as a contingency for appropriately modified meals.
  Stated by BupaStated in progress
6. Action
  Add safe-feeding materials and a competency check to the Nutrition and Hydration training module.
  Stated by BupaStated planned
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
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
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
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
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
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
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
4 May2020
Manchester South
Concerns raised1
1. Failure to ensure food is served at a safe temperature
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.
Respondent positions 2
1. Position
  Trafford Council was responsible for a safeguarding investigation if the hospital referred the burn incident under section 42.
  Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation TrustRedirects responsibility
1. Position
  Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
  Stated by Department of Health and Social CareRedirects responsibility
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
1 Oct2018
Brighton and Hove
Concerns raised1
1. Failure to maintain separation of cleaner and food-and-water handling roles
This report raised 11 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 1
1. Action
  Separate Host, Catering Assistant and Housekeeper roles, with dedicated Catering Assistants, differentiated uniforms and a Trust-wide rollout.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to check food brought into the home for suitability

Concerns raised1

Failure to prepare food safely for people at risk of choking

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.9

Concerns raised1

Failure to ensure food is served at a safe temperature

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

Concerns raised1

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

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

Actions described in response 9

Respondent positions 2

Actions described in response 1