Recurring concern

Unreliable dysphagia care and management

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First reported 6 Dec 2013•Latest report 22 May 2026

Definition

What this concern includes

Includes deficiencies in dysphagia-specific care and management, including staff competence and training, risk assessment, clinical investigation pathways, assessment, dietary guidance, communication and implementation of dysphagia precautions, when directly tied to dysphagia safety.

Not included

Generic staff training or capacity problems not specifically tied to dysphagia care.
Generic communication, documentation or staffing deficiencies without a direct dysphagia-safety connection.
Unrelated swallowing, feeding or nutritional issues that do not concern dysphagia risk management.

Reports: 6
Individual concerns: 8
Date range: 2013–2026
Stated actions: 11

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.

Ashley Gardens Care Centre1

East Kent Hospitals University NHS Foundation Trust1

Family1

Hc-One Limited1

NHS England1

Sandwell and West Birmingham Hospitals NHS Trust1

Somerset NHS Foundation Trust1

Walsall Healthcare NHS 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.

22 May2026
Somerset
Concerns raised1
1. Failure of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia
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.
Actions described in response 1
1. Action
  Deliver ward-based dysphagia and aspiration-risk education and promote IDDSI e-learning for clinical staff.
  Stated by NHS Somerset NHS Foundation TrustStated in progress
AI-generated summary

Jacqueline Marie Antoinette Frehe · 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

Jacqueline Marie Antoinette Frehe, aged 97, was admitted to hospital with swallowing difficulties, vomiting and suspected aspiration pneumonia. Her nil by mouth status was not communicated to ward staff, and she was given food and drink, after which she vomited, deteriorated significantly and died within about two hours. The concerns related to communication and documentation of nil by mouth status and checking this status when patients with dysphagia and suspected aspiration pneumonia arrive on the ward.

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 of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia
Wider context from the report
“I heard evidence from the Ward Manager. I was not satisfied that sufficient steps had been taken to ensure that: 1. patients’ nil by mouth status is effectively communicated from the emergency department on transfer of patients to a ward setting; and 2. communication of a patient’s nil by mouth status by family is clearly documented and communicated on the ward; and 3. ward staff question a patient’s nil by mouth status on receiving a patient with a presentation of dysphagia and suspected aspiration pneumonia. ”
Source location
Jacqueline Marie Antoinette Frehe · Prevention of Future Deaths report
Page 3 · 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
Deliver ward-based dysphagia and aspiration-risk education and promote IDDSI e-learning for clinical staff.

Verbatim wording from the response
“We are continuing to strengthen education and training for clinical staff in relation to dysphagia, aspiration risk, and safe management of nutrition and hydration. This includes targeted ward-based teaching and promotion of the International Dysphagia Diet Standardisation Initiative (IDDSI) e-learning programme, delivered in collaboration with our speech and language therapy colleagues. We would aim to have 90% of staff within the service group trained within the next 6 months. Our clinical skills facilitators are promoting this training alongside delivery of their snack box training in conjunction with our hydration and nutrition team.”

Source location
Response from Somerset NHS Foundation Trust
Page 3 · response
Published 25 August 2026
Open published response
23 Oct2025
Black Country
Concerns raised1
1. Lack of risk assessment determining when SALT assessments should take place for patients at risk of dysphagia
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Rashida Sultana · 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

Mrs Rashida Sultana died on 20 November 2024 after choking on chips and water while admitted to hospital. Concerns included confusion among nursing staff about when to call the Emergency Medical Response Team when a DNAR was in place, and insufficient risk assessment regarding Speech and Language Therapy assessments for patients at risk of dysphagia.

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
Lack of risk assessment determining when SALT assessments should take place for patients at risk of dysphagia
Wider context from the report
“3. In addition, there was a lack of risk assessment of when SALT assessments for those patients at risk of dysphagia should take place. ”
Source location
Mrs Rashida Sultana · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Mar2020
Central and South East Kent
Concerns raised1
1. Lack of a pathway for investigating dysphagia caused by an oesophageal stricture
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.
Respondent positions 1
1. Position
  Developing clinical pathways for oesophageal stricture is outside NHS England and NHS Improvement’s role.
  Stated by NHS EnglandOutside remit
AI-generated summary

Lynda Pedersen · 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

Lynda Pedersen died on 7 September 2018 in hospital from aspiration pneumonitis, pneumonia and fluid overload due to a stricture caused by an adenocarcinoma of the oesophagogastric junction. The adenocarcinoma was not identified during her admission or during earlier medical care following an admission for dysphagia. Concerns included the lack of a pathway for investigating dysphagia caused by a stricture, which contributed to the need to investigate malignancy being lost, and deficiencies in fluid balance charting and recording of fluid output before her death.

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
Lack of a pathway for investigating dysphagia caused by an oesophageal stricture
Wider context from the report
“(1) Lynda Pedersen was admitted to William Harvey Hospital on 6th September 2017 with dysphagia. A gastroscopy conducted two days later identified a stricture within the oesophagus with the appearance of the mucosa suggestive of a submucosal infiltration. A CT scan did not identify a malignancy but indicated that the area of concern could not be evaluated as it had not been distended by the orally ingested contrast. Lynda Pedersen had a number of further gastroscopies to attempt to dilate her oesophagus between 2017 and 2018 some of which reported a benign appearance but the cause of the stricture was never investigated despite the risk of variceal bleeding having been significantly reduced by a TIPS procedure having been conducted on 11th October 2017. It was accepted that a biopsy should have been undertaken but the need for investigation as to whether there was a malignancy was lost in that the clinicians’ focus was on attempting to improve her nutritional status and quality of life. The reason for the loss of the need for an investigation was twofold: there was no pathway in place for dysphagia presentation caused by a stricture and the fact of multiple presentations. It was agreed by the treating clinicians and an independent expert that had there been a pathway in place, the investigation for cancer was less likely to have been lost. The clinicians who gave evidence at the Inquest were of the view that this was a matter most appropriately addressed by NHS England and NHS Improvements. ”
Source location
Lynda Pedersen · Prevention of Future Deaths report
Page 1 · 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
Developing clinical pathways for oesophageal stricture is outside NHS England and NHS Improvement’s role.

Verbatim wording from the response
“While it is not the role of NHS England and Improvement to develop clinical pathways for conditions such as oesophageal stricture, other national bodies have done this. For example, the British Society of Gastroenterology 2018 guideline on managing dysphagia states: “obtain biopsies from all strictures to exclude malignancy” and “repeat biopsy after cross-sectional imaging in cases where biopsies are negative but clinical or endoscopic features are atypical or suspicious of malignancy”.”

Source location
2020-0112-Response-from-NHS-England-and-NHS-Improvement_Redacted.pdf
Page 2 · response
Published 10 June 2020
Open published response
14 Jan2020
Black Country
Concerns raised1
1. Failure to assess and advise on bread and bread products within dysphagia dietary guidance
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.
Actions described in response 3
1. Action
  Review and update the dysphagia policy to incorporate current IDDSI standards.
  Stated by Walsall Healthcare NHS TrustStated planned
2. Action
  Replace internally developed patient documents with IDDSI guidance covering food, fluids, portion sizes, bite sizes and transitional foods.
  Stated by Walsall Healthcare NHS TrustStated planned
3. Action
  Implement a staff checklist in patient records prompting and evidencing distribution of supportive and advisory documents.
  Stated by Walsall Healthcare NHS TrustStated planned
AI-generated summary

Mr Madhavbhai Khushalbhai Patel · 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

Mr Madhavbhai Khushalbhai Patel, a 95-year-old man living at home, choked on food during a meal on 13 May 2019 and died despite emergency treatment. Concerns included that the family had not been given the IDDSI definition of “bite sized”, and that there had been no specific assessment or advice concerning bread products or eating with his hands. The inquest did not find these matters causative or contributory to his death.

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 assess and advise on bread and bread products within dysphagia dietary guidance
Wider context from the report
“(1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm. (2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’. (3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’. (4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines. (5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands. The inquest did not find that any of the above matters were causative or contributory to death. ”
Source location
Mr Madhavbhai Khushalbhai Patel · 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 update the dysphagia policy to incorporate current IDDSI standards.

Verbatim wording from the response
“3. We will be reviewing and updating our dysphagia policy to fully incorporate the current IDDSI standards to ensure our delivery of care to patients in all settings is undertaken in adherence to these international best practice guidelines by June 2020.”

Source location
2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020
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
Replace internally developed patient documents with IDDSI guidance covering food, fluids, portion sizes, bite sizes and transitional foods.

Verbatim wording from the response
“4. We will be replacing our current internally developed patient documents with those provided by IDDSI which provide clearer visual guidance to patients and their families / carers about the recommended food and fluid intake as well as the appropriate size of portions and the size of each bite. These documents also include specific reference to ‘transitional foods’, such as breads or similar products such as roti and chapatti, with guidance and an assessment criteria for their consumption. We aim to complete this transition on or before April 1st 2020.”

Source location
2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020
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 a staff checklist in patient records prompting and evidencing distribution of supportive and advisory documents.

Verbatim wording from the response
“6. A revised checklist for staff will be implemented to be included within patients records to assure that staff are prompted to handout all relevant supportive and advisory documents to patients and their family / carers and that this can be evidenced. This too will form part of a revised policy but we would anticipate this coming into use prior to the final ratification of the policy to ensure patients are supported.”

Source location
2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020
Open published response
11 Apr2018
Nottinghamshire
Concerns raised3
1. Unavailability of SALT assessments in care plan files
2. Failure to adhere to SALT dietary recommendations
3. Lack of staff awareness of SALT supervision and dietary recommendations
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.
Actions described in response 6
1. Action
  Rewrite residents’ care plans to specify detailed individual care requirements.
  Stated by Hc-One LimitedStated completed
2. Action
  Share residents’ SALT fluid and diet requirements with catering, housekeeping, care and nursing staff.
  Stated by Hc-One LimitedStated completed
3. Action
  Introduce dining registers and quick-reference guides for managing specialist diets, with formal review and update governance.
  Stated by Hc-One LimitedStated completed
1. Action
  Implement and embed the required hospitality policy and process with kitchen staff.
  Stated by Hc-One LimitedStated completed
2. Action
  Assign the Care Manager oversight of communication and escalation between Speech and Language Therapy and home staff.
  Stated by Hc-One LimitedStated completed
3. Action
  Commission a three-day face-to-face dysphagia course for the home’s staff from an external expert provider.
  Stated by Hc-One LimitedStated planned
AI-generated summary

George Goldby · 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

George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and reviews.

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
Unavailability of SALT assessments in care plan files
Wider context from the report
“(6) The SALT assessment in respect of Mr Goldby had been archived and was not present on his care plan file at the time of his death. ”
Source location
George Goldby · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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 adhere to SALT dietary recommendations
Wider context from the report
“(2) Mr Goldby’s SALT recommendations were not being adhered to on 26.12.16 when he choked and recovered, nor on 20.03.17 when he choked again, directly leading to his death. Mr Goldby was not supervised one to one during his mealtimes. ”
Source location
George Goldby · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of staff awareness of SALT supervision and dietary recommendations
Wider context from the report
“(1) The nursing home staff were unaware of the SALT recommendations regarding Mr Goldby’s need for one to one supervision and dietary requirements. ”
Source location
George Goldby · 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
Rewrite residents’ care plans to specify detailed individual care requirements.

Verbatim wording from the response
“6. Once this initial work was completed at Stoneyford, we sought advice from senior clinicians within the company for governance and oversight, which resulted in the care plans being rewritten to specify the detailed plan of care for each Resident.”

Source location
2018-0104-Response-by-HC-One
Page 2 · response
Published 17 June 2018
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
Share residents’ SALT fluid and diet requirements with catering, housekeeping, care and nursing staff.

Verbatim wording from the response
“5. All existing fluid/diet requirements from SALT were shared with the whole team of colleagues working at the home. This includes the catering team, as well as housekeeping, care and nursing colleagues to ensure that as one team, the staff act as additional eyes and ears to protect Residents and prevent harm.”

Source location
2018-0104-Response-by-HC-One
Page 2 · response
Published 17 June 2018
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
Introduce dining registers and quick-reference guides for managing specialist diets, with formal review and update governance.

Verbatim wording from the response
“7. Additional advice was sought from the company Hospitality specialist to establish if there were any further processes or mechanisms to help support the safe and effective management of people who require a specialist diet. As a result we have introduced a new system of dining registers with quick reference guides, which were put into place and help colleagues or any agency workers to reflect the handover documentation.”

Source location
2018-0104-Response-by-HC-One
Page 2 · response
Published 17 June 2018
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 and embed the required hospitality policy and process with kitchen staff.

Verbatim wording from the response
“The hospitality specialist has supported the home and worked with colleagues working in the kitchen to implement and embed the policy and process that is required to be in place.”

Source location
2018-0104-Response-by-HC-One
Page 2 · response
Published 17 June 2018
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
Assign the Care Manager oversight of communication and escalation between Speech and Language Therapy and home staff.

Verbatim wording from the response
“4. The Care Manager has taken responsibility for oversight of communication between SALT and colleagues at the home to ensure optimum communication and appropriate escalation for support. This has been reported by all parties as very much improved, with greater clarity and swifter partnership working.”

Source location
2018-0104-Response-by-HC-One
Page 1 · response
Published 17 June 2018
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
Commission a three-day face-to-face dysphagia course for the home’s staff from an external expert provider.

Verbatim wording from the response
“We believe that there is no substitute for repeated learning opportunities that help inform staff of the consequences of not supporting Residents effectively and to that end have commissioned a three day face to face dysphagia course for the staff team from an external expert training provider. This is to supplement and extend the learning opportunities already available and refreshed by the team via our online award winning learning platform, Touchstone.”

Source location
2018-0104-Response-by-HC-One
Page 2 · response
Published 17 June 2018
Open published response
6 Dec2013
Mid Kent and Medway
Concerns raised1
1. Unavailability of sufficient dysphagia-awareness training places for all staff members
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
  Deliver private dysphagia-awareness training sessions to staff, including completed and scheduled sessions for up to 20 attendees.
  Stated by LIFESTYLE CARE (2011) PLCStated in progress
AI-generated summary

Keith Barton · 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

Keith Barton, who had Alzheimer’s disease and dementia and was at risk of choking, choked and died while eating breakfast alone in his room at a nursing home on 5 February 2013. The principal concerns included unclear communication of the required level of supervision, periodic rather than constant checks while eating, incomplete incident reporting, and limits on staff access to dysphagia awareness training.

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
Unavailability of sufficient dysphagia-awareness training places for all staff members
Wider context from the report
“(2) That external training in relation to dysphagia awareness which had been put in place following the death of Mr. Barton could not be delivered to all staff members because of constraints on the number of places available (which could potentially be resolved by in-house training) ”
Source location
Keith Barton · 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
Deliver private dysphagia-awareness training sessions to staff, including completed and scheduled sessions for up to 20 attendees.

Verbatim wording from the response
“As a result of the above I sourced some dysphagia awareness training from a private SALT therapist. She has experience of delivering dysphagia training to difference healthcare professions across nursing homes, day centres and hospitals. Her training is based on literature, published research and her own experience in the sector. She has over 12 years of clinical experience as a speech and language therapist and is now an independent practitioner. She is registered with The Royal College of Speech and Language Therapists and Healthcare and Professions Council.”

Source location
2013-0330-Response-by-Life-Style-Care
Page 2 · response
Published 23 February 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of ward staff to question a patient’s nil by mouth status when receiving a patient with dysphagia and suspected aspiration pneumonia

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

Lack of risk assessment determining when SALT assessments should take place for patients at risk of dysphagia

Concerns raised1

Lack of a pathway for investigating dysphagia caused by an oesophageal stricture

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to assess and advise on bread and bread products within dysphagia dietary guidance

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

Concerns raised3

Unavailability of SALT assessments in care plan files

Failure to adhere to SALT dietary recommendations

Lack of staff awareness of SALT supervision and dietary recommendations

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.6

Concerns raised1

Unavailability of sufficient dysphagia-awareness training places for all staff members

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 1

Respondent positions 1

Actions described in response 3

Actions described in response 6

Actions described in response 1