Recurring concern

Unreliable management of specialist modified diets

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First reported 3 Apr 2018•Latest report 10 May 2024

Definition

What this concern includes

Includes failures of controls dedicated to prescribing, explaining, communicating, implementing, supervising or checking specialist modified diets, including modified food or fluid consistencies and adherence to SALT or equivalent clinical guidance.

Not included

  • Excludes general nutrition and hydration deficiencies where no specialist modified-diet requirement is identified.
  • Excludes generic staff training, communication or documentation deficiencies unless they directly impair management of a specialist modified diet.
  • Excludes choking or aspiration response failures occurring after the modified diet was correctly understood and followed.
  • Excludes ordinary food preferences, dietary choices or meal-service deficiencies unrelated to a clinically required modified diet.
Reports
6

Distinct published reports

Individual concerns
10

A report can raise multiple concerns

Date range
2018–2024

First to latest report issue date

Stated actions
11

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.

Care Quality Commission3
Department of Health and Social Care1
Haddon Court Limited1
Harbour Healthcare Ltd.1
Highgrove Rest Home1
Hilltop Court Nursing Home1
Sheffield Teaching Hospitals NHS Foundation Trust1
South West Yorkshire Partnership Teaching NHS Foundation Trust1
Stars Social Support Limited1

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.

  1. Blackpool and the Fylde

    AI-generated summary

    Mr Terence John Manning · 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 Terence John Manning, a resident of Haddon Court Rest Home, experienced a choking incident while eating a meal on 22 October 2023 and died in hospital on 24 October 2023. The concerns included inaccurate care records caused by carers carrying forward records from other residents, meaning the records did not reflect the food being given to him, and the absence of a Speech and Language Therapy referral despite a known propensity to eat quickly.

    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 a pureed or soft texture diet

    Wider context from the report

    “Mr Terence John Manning was a resident at Haddon Court from 29 June 2023. It was known to Haddon Court Rest Home, that Mr Manning had a propensity to eat quickly and to take food from other plates. Mr Manning was not being fed a pureed or soft texture diet, and entries to this effect in the care records are errors in the record keeping. These errors had been caused by carers carrying forward the details of records relating to other residents from entries made on the records of those other residents. It was noted in the evidence, that erroneous record keeping had taken place over a period of time and involved multiple carers. It was caused by carers transposing the records of one resident into the care records of another, leading to inaccuracies. I found that these matters gave rise to a risk of future death as the record keeping was inaccurate and did not reflect the foods being given to Mr Manning, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. ”

    Source location

    Mr Terence John Manning · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Blackpool and the Fylde

    AI-generated summary

    Mr Terence Burns · 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 Terence Burns, a resident of Highgrove Rest Home, was transferred to hospital on 28 October 2022 after his physical condition deteriorated. His blended-diet requirement was not communicated to ambulance services or the hospital, and he was later found unresponsive with food residue in his throat and died. Concerns included inaccurate care-plan information about his nutritional needs and failure to check the documents handed over during transfer.

    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 care plans with accurate nutritional requirements

    Wider context from the report

    “The written care plan that was in place at Highgrove Rest Home did not contain the information that Mr Burns required a blended diet. Having heard the oral evidence from the two carers who attended the inquest to give evidence, I accepted that Mr Burns was being fed a blended diet in advance of his attendance at hospital on 28 October 2022. I found that the monthly reviews of the care plan, that were carried out on 4 September and 8 October 2022, did not amend the care plan to include the need for a blended diet, and accordingly the written care plan did not accurately define the nutritional needs of Mr Burns. This missing information from the care plan was a concern for me as the documentary evidence relating to the nutritional requirements of Mr Burns was not correct. ”

    Source location

    Mr Terence Burns · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. South Yorkshire (Western)

    AI-generated summary

    Anthony Wilkinson · 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

    Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.

    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

    Unclear SALT guidance on consistency descriptions and modified or avoided foods

    Wider context from the report

    “(18)The advice from SALT was not an issue in this case, it was the application of this advice which was the primary concern. I would like to commend the approach that the Trust have taken in learning from the issues which I raised at the conclusion of the proceedings and the openness with which the Trust have received the concerns I had. The guidance sheets which have been produced are still not clear enough and will lead to confusion including around the consistency description and a list of foods which can be modified or should be avoided. This needs to be reviewed to avoid confusion. ”

    Source location

    Anthony Wilkinson · Prevention of Future Deaths report
    Page 5 · 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

    Revise and implement level 6 food consistency advice sheets by removing misleading images, clarifying wording, and separating avoidable foods from modifiable options.

    Verbatim wording from the response

    “On 18th May 2021, ████████ along with other Learning Disability Speech and Language Therapists, met and reviewed the services level 6 food consistency advice sheets in their Dysphagia Speech and Language Therapy Learning Disability meeting. As a result of this review, the advice sheets were amended in response to your concerns as follows:”

    Source location

    2021-0102-Response-from-South-West-Yorkshire-Partnership-NHS-Foundation-Trust-Redacted
    Page 1 · response
    Published 13 April 2021

    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

    A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.

    Verbatim wording from the response

    “A decision has been taken by the Registered Manager and Director of Stars Social Support Limited for the organisation to cease to continue. The Registered Manager and Director at Stars Social Support Limited has contacted the Local Authority and the Care Quality Commission to notify them that Stars Social Support Limited will cease to continue.”

    Source location

    2021-0102-Response-from-Stars-Social-Support-Ltd-Redacted
    Page 1 · response
    Published 13 April 2021

    Open published response

  4. South Yorkshire (West)

    AI-generated summary

    Joan Howard · 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

    Joan Howard was admitted to hospital on 4 April 2019 with specialist dietary requirements and choked to death on 10 April 2019 after being given a sandwich that should not have been provided. The report identified failures to follow dietary guidance and hospital processes, act on information from her care home, provide appropriate fluids, and escalate concerns about inappropriate food. It found that neglect had contributed to 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

    Delays in displaying nutritional requirements at the bedside

    Wider context from the report

    “g) Temporary posters for Joan’s nutritional needs were placed above Joan’s bed by staff once they became aware of the need for Joan to have a special diet. This was over 12 hours after her admission to the ward and therefore covered an evening meal, breakfast and lunch, during which inappropriate diet could have been given to Joan and definitely was at lunch time. This was despite information being available to the Ward from the care home Joan had been brought in from about her nutritional requirements. Additionally, the Royal Hallamshire Hospital where she had been discharged from earlier the same day before admission to the Northern General Hospital, had information about her nutritional requirements. It wasn’t until the family noticed that Joan had been given a sandwich at lunch time on 5 April 2019 that staff placed temporary posters above her bed. ”

    Source location

    Joan Howard · 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 escalate inappropriate dietary choices to the clinical team

    Wider context from the report

    “e) The Senior Sister on the ward confirmed that where someone had capacity and made an unwise choice which contradicted the indication from speech and language therapy, she would expect staff to escalate this to the clinical team to have a discussion with the patient. This was confirmed by the Matron responsible for the presentation of the Serious Incident Investigation at Court however in Joan’s case, if staff were aware that the choice of two sandwiches and a piece of cake were inappropriate for Joan, they did not escalate this to the clinical team. ”

    Source location

    Joan Howard · 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 provide food consistent with specialist nutritional requirements

    Wider context from the report

    “a) The SALT input into Joan’s care was exemplary. She had appropriate assessments and following a visit on the ward the day after her admission appropriate clear posters were placed above Joan’s bed confirming what nutrition she could have. Despite these posters, on two occasions Joan was provided with inappropriate food. ”

    Source location

    Joan Howard · 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 follow ward processes for managing specialist nutritional requirements

    Wider context from the report

    “c) The Senior Sister on the ward gave evidence which confirmed that there are processes in place for the management of specialist nutritional requirements on the ward however in this case these were not appropriately followed by staff. d) The Senior Sister on the ward confirmed that she would expect her staff to follow the guidelines issued by the speech and language therapy team and to understand what was meant by level 2 fluids and level 6 food. This was not the case in practice. ”

    Source location

    Joan Howard · 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 of staff to understand and follow specialist diet guidelines

    Wider context from the report

    “c) The Senior Sister on the ward gave evidence which confirmed that there are processes in place for the management of specialist nutritional requirements on the ward however in this case these were not appropriately followed by staff. d) The Senior Sister on the ward confirmed that she would expect her staff to follow the guidelines issued by the speech and language therapy team and to understand what was meant by level 2 fluids and level 6 food. This was not the case in practice. ”

    Source location

    Joan Howard · 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

    Update, disseminate and make available the ward meal-service SOP covering mealtime safety huddles and dietary requirements.

    Verbatim wording from the response

    “Following the inquest, the SOP (attached) has been updated to include a description of the purpose and approach to the mealtime safety huddle. It has also been updated so that reference is made to specialist advice on patient fluid consistency and special dietary requirements in relation to snack boxes and light bites. The updated SOP is a key component of the e-learning package. It has been shared with matrons, included in the Catering Folder on each ward, and is available to order through the Trust’s ‘Xerox ‘print on demand’ process. Compliance with the SOP will be audited as described above.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 3 · response
    Published 14 January 2021

    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

    Record IDDSI eating, drinking, texture and fluid requirements on the Electronic Whiteboard and populate multidisciplinary handover sheets.

    Verbatim wording from the response

    “Work has now been completed to incorporate the national IDDSI descriptors into the Electronic Whiteboard (EWB). This work had already been planned, but was expedited as a result of this incident. As a consequence, patients’ eating and drinking requirements, food texture and fluid consistency are now recorded on EWB. This is a visible prompt to all ward staff (not just nurses) about the patient’s individual requirements. This information then automatically populates the multi-disciplinary handover sheet that is printed from the EWB for ward staff to refer to. The EWB is recognised as a prime Multi-Disciplinary Team handover and effective communication tool within the Trust.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 4 · response
    Published 14 January 2021

    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

    Provide wards with IDDSI diet signage and related patient information forms, including visible IDDSI level descriptions.

    Verbatim wording from the response

    “For those patients who are admitted to hospital already requiring texture modified diets in the community, the ward teams can now record the information straight onto the EWB and the correct diet signage can be placed above the patient’s bed immediately. The SOP prompts staff to ensure that swallowing assessment detail is placed above the patient’s bed, and wards will now be provided with a supply of signage and related patient information forms so that temporary signage will not be required. Signage is also available to order through the Xerox ‘print on demand’ service and can be downloaded from the Trust intranet site. Signage now also includes a description of the IDDSI levels alongside the level of diet the patient is on, so that this information is clearly visible and easily accessible for staff ‘at a glance’.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 4 · response
    Published 14 January 2021

    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 mandatory IDDSI training to Job Specific Essential Training for staff involved in mealtime procedures.

    Verbatim wording from the response

    “It is accepted that this approach did not make IDDSI training mandatory, nor could we be sure that every member of staff involved in mealtime procedures (including, for example, housekeepers) had received training in IDDSI through the cascade mechanism. We recognise the need for all staff engaged in mealtime duties to receive training in IDDSI and this will be achieved as outlined below:”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 14 January 2021

    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 the finalised Meal Service Safety e-learning package covering IDDSI, the SOP, mealtime safety huddles and hot-food handling.

    Verbatim wording from the response

    “• IDDSI training will no longer be delivered by cascade, but through an e-learning package entitled ‘Meal Service Safety’. This approach will ensure consistency, appropriate levels of understanding, and refresher training. The training package will consist of three elements: IDDSI, the Standard Operating Procedure (SOP) which was shared at the inquest and has since been updated (copy attached), and guidance on handling hot food. The training will ensure staff are familiar with IDDSI principles and terminology, and all stages in the SOP. There will be specific focus on the ‘Safety Pause’ which has now been labelled the ‘Mealtime Safety Huddle’ as this is a concept with which nurses are already familiar. The e-learning will also include guidance on handling hot food which, although not an issue in the serious incident, is important in maintaining staff safety.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 14 January 2021

    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

    Expand the HANAT and Power of 3 audits to monitor IDDSI, SOP and hot-food-handling compliance.

    Verbatim wording from the response

    “• Compliance with IDDSI, including the SOP, will be monitored through two existing audits which will be expanded to include IDDSI compliance. The first audit is the biannual Hydration and Nutrition Assurance Toolkit (HANAT). This has been updated to include specific questions in relation to the SOP and will be reviewed again by the Nutrition Steering Group prior to the next audit to include questions in relation to handling of hot food. The second audit is the annual ‘Power of 3’ audit of meal service, which has been updated to include audit of IDDSI, SOP compliance, and handling of hot food. This audit is undertaken by representatives from catering, dietetics, and senior nursing and involves the completion of an audit of meal service on one ward in each of the care groups annually.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 14 January 2021

    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

    Mandate the Meal Service Safety e-learning package within the Prepare to Care programme for trainee clinical support workers.

    Verbatim wording from the response

    “• In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners. The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In the meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 14 January 2021

    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

    Maintain Mealtime Safety Huddles as an additional safety barrier for staff involved in mealtimes.

    Verbatim wording from the response

    “• In relation to trainees and students, Trainee CSWs receive their training through our Prepare to Care programme. This includes a nutrition module which covers aspects of nutrition including swallowing, dysphagia and mixing drink thickeners. The training does not currently cover IDDSI, however the new e-learning package will now be mandated as part of the Prepare to Care programme. In the meantime, the SOP and the Mealtime Safety Huddles will include CSWs, along with other staff involved in mealtimes, to support safe mealtime service.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 14 January 2021

    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

    Consider how to achieve consistency in IDDSI training for student nurses across the two universities.

    Verbatim wording from the response

    “• Student nurses receive formal training through the universities and this includes teaching regarding dysphagia, swallowing, thickening, and SALT. They also spend 50% of their experience in practice and this will include practical training and supervision when caring for patients with dysphagia. Both Sheffield Hallam University and the University of Sheffield cover these elements within their student nurse training programmes, however the University of Sheffield training programme also incorporates IDDSI training. Consistency in student nurse training is therefore an issue which will need further discussion and we will give this matter appropriate consideration as soon as is practicable.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 3 · response
    Published 14 January 2021

    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

    Consider extending mandatory IDDSI training to non-Trust bank and agency staff.

    Verbatim wording from the response

    “• Regarding bank and agency staff working within the Trust, these staff are recruited through NHS Professionals, and many are existing STH staff working additional hours over their contracted hours. These staff will have received their training as part of their substantive role. For non-STH employees, IDDSI does not form part of the mandatory training provided by NHS Professionals and this is therefore an issue which we will consider further as soon as practicable. In the interim, the additional measures now in place through the SOP and the Mealtime Safety Huddles, which are the responsibility of Trust Registered Nurses, will provide a further safety barrier at mealtimes.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 3 · response
    Published 14 January 2021

    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

    COVID-19 operational pressures prevent implementing all planned safety changes in the near future.

    Verbatim wording from the response

    “Having outlined the actions we have agreed to take in response to this incident and to the PFD Report, I hope that I have been able to convey how seriously we have viewed this matter. Whilst we will be unable to implement all these changes in the near future, given the urgency of the situation in relation to COVID-19, we are absolutely committed to learning from Mrs Howard’s death and implementing the remaining actions at the earliest opportunity.”

    Source location

    2021-0007-Response-from-Sheffield-Teaching-Hospitals-NHS-Foundation-Trust_Redacted
    Page 4 · response
    Published 14 January 2021

    Open published response

  5. Manchester South

    AI-generated summary

    Jane Olive Parker · 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

    Jane Olive Parker, who had dementia and a history of choking episodes, was found unresponsive approximately 40 minutes after eating an inappropriate meal unobserved in her room on 24 August 2016. Post-mortem examination found un-chewed food in her airway, and the recorded conclusion was death from aspiration of food, contributed to by neglect. Concerns included poor understanding and preparation of modified diets, and failures to escalate choking episodes to the Speech and Language Team for reassessment.

    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 care assistant understanding of modified diets and adherence requirements

    Wider context from the report

    “1. There was poor understanding by the care home assistants of what was meant by the types of modified diets that could be recommended by the SALT teams. Following Mrs Parker’s death both the Local Authority in question and the Care Home provider had taken steps to improve knowledge within their care homes but it was unclear if there were national programmes to ensure that care assistants understood modified diets and the importance of adherence to them; ”

    Source location

    Jane Olive Parker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester South

    AI-generated summary

    Barbara Haley · 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

    Barbara Haley inhaled vomit, saliva, food or liquid while resident at Hilltop Court Care Home, developed a chest infection, and died at Stepping Hill Hospital on 13 October 2017 after suffering a cardiac arrest en route. Concerns included her being provided food unsuitable for her soft diet and being left alone to eat despite having been assessed as at high 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

    Provision of food unsuitable for a soft diet

    Wider context from the report

    “1. Mrs Haley was on a soft diet (described as a “fork-mashable diet” in evidence). Despite this, there was evidence that Mrs Haley had been provided with food items not suitable for her by staff. In particular, on one occasion toast was found in her room. On another occasion, staff had apparently suggested to a family member that chocolate could be given to Mrs Haley. ”

    Source location

    Barbara Haley · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026