Recurring concern

Failure to provide food providers with safety-critical care information

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First reported 1 Sep 2017•Latest report 11 May 2018

Definition

What this concern includes

Includes failures to provide, communicate, confirm or maintain relevant care plans, dietary requirements, choking precautions, feeding instructions or comparable safety-critical information for organisations, staff, carers or visitors responsible for providing food to a vulnerable person.

Not included

Excludes general care-plan, record-keeping or information-sharing failures where the recipient is not responsible for providing food.
Excludes nutrition, hydration, choking or dysphagia-management failures where the food-provider information interface is not itself deficient.
Excludes failures in the quality or safety of food provision after the responsible provider has reliably received and understood the relevant care information.
Excludes generic communication, staffing or training deficiencies that are not directly tied to supplying safety-critical care information to a food provider.

Reports: 2
Individual concerns: 2
Date range: 2017–2018
Stated actions: 4

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.

Aspray House Ltd1

Birmingham City Council1

Birmingham Community Healthcare NHS Foundation Trust1

Cater Link Limited1

The Olive School, Small Heath1

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.

11 May2018
London (East)
Concerns raised1
1. Failure to provide visitors with robust written procedures and information for safely providing food to patients at risk of 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.
Actions described in response 1
1. Action
  Implement revised care policies and processes across the group’s homes to improve resident safety.
  Stated by Aspray House LtdStated completed
AI-generated summary

Ahmed Amin TABECHE · 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

Ahmed Amin TABECHE died at Aspray Care Home on 15 September 2016 after choking while being fed vegetable soup containing pieces of vegetables. The report identified insufficient guidance and supervision about his feeding requirements, and inadequate systems and written information for visitors feeding a person at risk of choking.

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 provide visitors with robust written procedures and information for safely providing food to patients at risk of choking
Wider context from the report
“(2) I note that action has been taken by the Care Home to place more posters around the Home, informing visitors to notify the nurse in charge before giving food to the loved ones. I do not consider that this is sufficient to address the concerns that have arisen in this case. The visitor who had been feeding Mr Tabeche confirmed that he focussed fully on Mr Tabeche when he attended. He did not read posters which were located inside Mr Tabeche’s room. He was not given any written information on the risk of choking; the type of food that Mr Tabeche should receive, or how he should be fed. More robust, written procedures around visitors and the provision of food may assist in providing a safer environment. ”
Source location
Ahmed Amin TABECHE · Prevention of Future Deaths report
Page 1 · 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 revised care policies and processes across the group’s homes to improve resident safety.

Verbatim wording from the response
“As a company we treat such matters very seriously and have moved swiftly to re-evaluate our policies and processes to ensure that we are providing the best possible care to our residents in the safest way possible.”

Source location
2018-0143-Response-by-Twinglobe
Page 1 · response
Published 1 July 2018
Open published response
1 Sep2017
Birmingham and Solihull
Concerns raised1
1. Failure to provide issued care plans to the food provider
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 3
1. Action
  Review and rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.
  Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completed
2. Action
  Conduct routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.
  Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completed
3. Action
  Implement allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.
  Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completed
AI-generated summary

Mohammad Ismaeel Ashraf · 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

Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.

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 provide issued care plans to the food provider
Wider context from the report
“3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be. ”
Source location
Mohammad Ismaeel Ashraf · 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
Review and rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.

Verbatim wording from the response
“The School was very concerned to hear the evidence given by the uncle of the deceased at the inquest that the Health Care Plan for Ismael’s sister was inaccurate. At the time of the inquest the pupils were on the six week summer holiday and so neither pupil nor any other pupils were being put at risk at the time the evidence came to light. The School took immediate steps, before the school re-opened in September 2017, to review and rectify any inaccuracies.”

Source location
2017-0243-Response-by-Al-Hijrah-School
Page 2 · response
Published 2 October 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
Conduct routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.

Verbatim wording from the response
“The School has implemented a routine half termly check of all Health Care Plans displayed at key locations and held by the catering teams, which are cross checked against the master list held centrally at the school.”

Source location
2017-0243-Response-by-Al-Hijrah-School
Page 2 · response
Published 2 October 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
Implement allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.

Verbatim wording from the response
“Aside from the monthly meetings the School has implemented a robust system to ensure that the catering staff are notified of any new allergy information as soon as the School is notified. The pupil is added to the pre-order list and a prepared lunch is provided to the pupil by the catering team. The pupil is accompanied to lunch by a member of staff. A record is kept of all notifications made to the catering team. The pupil is issued once a Health Care Plan has been issued by the School, which is signed by both the catering manager and a signed record kept of delivery and receipt of the Health Care Plan to the catering manager.”

Source location
2017-0243-Response-by-Al-Hijrah-School
Page 5 · response
Published 2 October 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide visitors with robust written procedures and information for safely providing food to patients 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.1

Concerns raised1

Failure to provide issued care plans to the food provider

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

Actions described in response 1

Actions described in response 3