Includes failures of controls specifically dedicated to assessing, preventing or managing aspiration risk, including aspiration-exclusion testing, relevant clinical policies and procedures, staff understanding of those controls, and their application to patients prone to aspiration.
What is not included
Excludes general swallowing, nutrition or respiratory-care deficiencies that are not specifically tied to aspiration risk.
Excludes failures limited to treatment of aspiration pneumonia after aspiration has occurred unless they also concern the aspiration-prevention or assessment process.
Excludes generic training, communication, documentation or staffing deficiencies unless they directly impair an aspiration-specific control.
Excludes unrelated diagnostic tests and clinical assessments where aspiration is not the identified safety concern.
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
Most frequent recipients
Reports about this concern sent to each recipient.
Central and North West London NHS Foundation Trust1
Greater Manchester Police1
Milton Keynes University Hospital1
University Hospitals Plymouth NHS Trust1
NHS trust2
Healthcare site1
Police force1
Reports and published responses 3 reports
See individual reports that have raised this concern, and the actions taken in response
Milton Keynes
Concerns raised1
Lack of understanding of aspiration investigation and management policies and procedures
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Central and North West London NHS Foundation Trust
Milton Keynes University Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
Central and North West London NHS Foundation Trust
Provide enhanced safe-swallowing training covering referrals, recommendations and practical preparation of compliant drinks and snacks.
Milton Keynes University Hospital NHS Foundation Trust
Establish a multiprofessional group to develop dysphagia resources for wards and departments.
Milton Keynes University Hospital NHS Foundation Trust
Ensure staff understand thickened-fluids guidance and can identify and prepare appropriate diets.
Milton Keynes University Hospital NHS Foundation Trust
Review current nutritional and dysphagia training.
Milton Keynes University Hospital NHS Foundation Trust
Develop a dedicated dysphagia policy.
Milton Keynes University Hospital NHS Foundation Trust
Introduce practical training on special-diet textures and preparation.
Milton Keynes University Hospital NHS Foundation Trust
Issue a clinical-leader call to action on diet, fluid management and staff training responsibilities.
Milton Keynes University Hospital NHS Foundation Trust
Deliver Fundamentals of Care training for clinical staff, including nutrition, hydration and special-diet content.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Milton Keynes University Hospital NHS Foundation Trust
Implemented dysphagia-care measures are considered sufficient to fulfil the Regulation 28 requirements and ensure safe, appropriate care.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Plymouth, Torbay and South Devon
Concerns raised2
Failure to perform a sip test to exclude aspiration
Failure to identify or remedy the absent aspiration-exclusion test
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Plymouth NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
University Hospitals Plymouth NHS Trust
Sip checking is basic post-recovery care, not a diagnostic test for perforation, and its small fluid volume would not cause mediastinitis.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Inconsistent guidance on safe positioning of confused or intoxicated prisoners
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Greater Manchester Police
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
Greater Manchester Police
Deliver annual specialist training on current detainee restraint techniques and continually review those methods using operational, professional and case-review feedback.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Greater Manchester Police
No approved technique permits leaving a detainee on their back in a police cell, contrary to the concern that this position complied with guidance.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.