Recurring concern

Inadequate provision of food for care residents

First to latest report 26 Sep 2014 — 24 Feb 2026

Reports that mention this concern: 14
Times this concern has been raised: 15
Stated actions linked to this concern: 25

What this concern includes

Includes deficiencies in the end-to-end provision of food to care residents, including shortages, unsuitable or limited dietary options, preparation or presentation failures, and failure to provide required mealtime assistance.

What is not included

Excludes generic staff shortages unless they are specifically tied to inadequate food provision.
Excludes shortages of general equipment unless the evidence specifically ties the equipment failure to food provision.
Excludes unrelated shortages of placements, beds, clinical staff, interpreting services or other resources.
Excludes fluid-intake monitoring or documentation failures unless they are part of a directly evidenced food-provision deficiency.

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

Reports about this concern sent to each recipient.

Care Quality Commission3

Department of Health and Social Care2

Adelaide Medical Centre, London1

Bolton Borough Council1

Bramling Cross Registrations Limited1

Bupa Care Homes (GL) Limited1

Cardinal HC Limited1

Care First Homes1

Caring UK Limited1

Greater Manchester Health and Social Care Partnership1

Greater Manchester Mental Health NHS Foundation Trust1

Harbour Healthcare Ltd.1

Hill Care Group1

Hilltop Court Nursing Home1

Leeds Teaching Hospitals NHS Trust1

Reports and published responses 14 reports

See individual reports that have raised this concern, and the actions taken in response

3 Apr2018
Manchester South
Concerns raised1
1. Provision of food unsuitable for a soft diet
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
7 Oct2016
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Shortage of food and other equipment
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Norman Arthur BEARD · 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

Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

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
Shortage of food and other equipment
Wider context from the report
“(3) Financial difficulties led to shortage of staff, food and other equipment. ”
Source location
Norman Arthur BEARD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Aug2015
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Failure to provide food in the required softened form
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response

University Hospitals of North Midlands NHS Trust
Respondent positions 2
1. University Hospitals of North Midlands NHS Trust
  Staff could not recall baked beans being served, and such food would not usually form part of an easy-chew diet.
  Disputes the concern
1. University Hospitals of North Midlands NHS Trust
  Traffic-light instructions, documented dietary requirements, nutritional assessments, daily intake support and SALT referral procedures were considered sufficient safeguards.
  Existing arrangements considered sufficient
AI-generated summary

Stephen Richardson · 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

Stephen Richardson, who had Down syndrome and lived in a care home, suffered a fractured pelvis after an unrecognised injury and later developed a chest infection before dying in hospital on 16 January 2015. Concerns were raised about hospital nursing care, including the provision of solid food and inappropriate drinking equipment despite recorded instructions, which might have caused aspiration.

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 food in the required softened form
Wider context from the report
“At the inquest I heard evidence from two professional carers for the deceased. They drew to my attention concerns which arose from nursing on ward 225 at the Royal Stoke University Hospital. Care was needed with what the deceased took orally. His food needed to be softened and drinks had to be given via a normal cup or glass. He had Downs Syndrome and he did not know better himself. He was, despite notices above his bed, fed chocolate biscuits, pastry, baked beans and other solid foods all of which he might have aspirated. Drinks were often given with Tippee cups or in glasses with straws, both of which were inappropriate and again could have caused aspiration. Four copies of ‘traffic light notes’ were handed in to avoid this type of problem and the carers when visiting consistently had to reinforce these messages to nursing staff. It is unlikely that he did aspirate but he might have done. It is depressing to note the frequent lack of care and attention to detail and I would like a report from the Ward Manager as to the issues raised. ”
Source location
Stephen Richardson · Prevention of Future Deaths report
Page 2 · 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
Staff could not recall baked beans being served, and such food would not usually form part of an easy-chew diet.

Verbatim wording from the response
“Throughout the nursing documentation nutritional assessments were completed and it is clearly documented there were no concerns in this regard. Whilst it is difficult to provide a comprehensive response in regard to the comment that Mr Richardson was provided baked beans, Sr Shaw has sought a view from her staff and none are able to recall him receiving baked beans as part of his diet. Sr Shaw and the staff rely on the catering staff to provide appropriate meals for an easy chew diet and she is of the understanding that baked beans do not usually form part of this diet so it would be unusual for them to be served.”

Source location
2015-0507-Response-by-University-Hopsitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 18 August 2015
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
Traffic-light instructions, documented dietary requirements, nutritional assessments, daily intake support and SALT referral procedures were considered sufficient safeguards.

Verbatim wording from the response
“Mr Richardson was initially admitted to Ward 226 on the 24th December 2014 but was subsequently transferred over to Ward 225 a few days later. On admission there were no signs of erratic breathing, rendering it difficult for Mr Richards to suck informally from a straw. This suggest that he did not receive too much liquid leading to a cough; if this had been the case, the nursing staff would have made an immediate referral to the SALT (Speech and Language Therapy) Team, as per Trust protocol.”

Source location
2015-0507-Response-by-University-Hopsitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 18 August 2015
Open published response
26 Sep2014
Preston and West Lancashire
Concerns raised1
1. Failure of food provision and presentation procedures to accommodate residents requiring modified food preparation and assistance
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dorothy Mavis Clarkson · 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

Dorothy Mavis Clarkson choked on a large piece of meat while eating at Longton Nursing and Residential Home on 25 July 2013, became unresponsive, and died in hospital on 27 July 2013. The substantive concerns related to how food was provided and presented to residents requiring modified food or assistance, and to appropriate ongoing professional training for nursing staff.

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 food provision and presentation procedures to accommodate residents requiring modified food preparation and assistance
Wider context from the report
“(1) the procedure by which food is provided and presented to residents who require food to be prepared in a certain way and who need assistance by virtue of their physical or mental condition; ”
Source location
Dorothy Mavis Clarkson · Prevention of Future Deaths report
Page 2 · concerns
Open source report