First reported 23 Jul 2019•Latest report 18 Jun 2025
Definition
What this concern includes
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.
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.
Reports
3
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2019–2025
First to latest report issue date
Stated actions
9
Described in published responses
Reports over time
Reports 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
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.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.8
Action
Provide enhanced safe-swallowing training covering referrals, recommendations and practical preparation of compliant drinks and snacks.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Establish a multiprofessional group to develop dysphagia resources for wards and departments.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Ensure staff understand thickened-fluids guidance and can identify and prepare appropriate diets.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Review current nutritional and dysphagia training.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Develop a dedicated dysphagia policy.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Introduce practical training on special-diet textures and preparation.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Issue a clinical-leader call to action on diet, fluid management and staff training responsibilities.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Deliver Fundamentals of Care training for clinical staff, including nutrition, hydration and special-diet content.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implemented dysphagia-care measures are considered sufficient to fulfil the Regulation 28 requirements and ensure safe, appropriate care.
Stated by Milton Keynes University Hospital NHS Foundation TrustExisting 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Sip checking is basic post-recovery care, not a diagnostic test for perforation, and its small fluid volume would not cause mediastinitis.
Stated by University Hospitals Plymouth NHS TrustDisputes 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Deliver annual specialist training on current detainee restraint techniques and continually review those methods using operational, professional and case-review feedback.
Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 9 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No approved technique permits leaving a detainee on their back in a police cell, contrary to the concern that this position complied with guidance.
Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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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.
