Recurring concern

Failure to provide food providers with safety-critical care information

First to latest report 1 Sep 2017 — 11 May 2018

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
4

What this concern includes

Includes failures to provide, communicate, confirm or maintain relevant care plans, dietary requirements, choking precautions, feeding instructions or comparable safety-critical information for organisations, staff, carers or visitors responsible for providing food to a vulnerable person.

What is not included
  • Excludes general care-plan, record-keeping or information-sharing failures where the recipient is not responsible for providing food.
  • Excludes nutrition, hydration, choking or dysphagia-management failures where the food-provider information interface is not itself deficient.
  • Excludes failures in the quality or safety of food provision after the responsible provider has reliably received and understood the relevant care information.
  • Excludes generic communication, staffing or training deficiencies that are not directly tied to supplying safety-critical care information to a food provider.

Reports and published responses 2 reports

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

  1. London (East)

    AI-generated summary

    Ahmed Amin TABECHE · 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

    Ahmed Amin TABECHE died at Aspray Care Home on 15 September 2016 after choking while being fed vegetable soup containing pieces of vegetables. The report identified insufficient guidance and supervision about his feeding requirements, and inadequate systems and written information for visitors feeding a person at 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

    Failure to provide visitors with robust written procedures and information for safely providing food to patients at risk of choking

    Wider context from the report

    “(2) I note that action has been taken by the Care Home to place more posters around the Home, informing visitors to notify the nurse in charge before giving food to the loved ones. I do not consider that this is sufficient to address the concerns that have arisen in this case. The visitor who had been feeding Mr Tabeche confirmed that he focussed fully on Mr Tabeche when he attended. He did not read posters which were located inside Mr Tabeche’s room. He was not given any written information on the risk of choking; the type of food that Mr Tabeche should receive, or how he should be fed. More robust, written procedures around visitors and the provision of food may assist in providing a safer environment. ”

    Source location

    Ahmed Amin TABECHE · Prevention of Future Deaths report
    Page 1 · 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

    Implement revised care policies and processes across the group’s homes to improve resident safety.

    Verbatim wording from the response

    “As a company we treat such matters very seriously and have moved swiftly to re-evaluate our policies and processes to ensure that we are providing the best possible care to our residents in the safest way possible.”

    Source location

    2018-0143-Response-by-Twinglobe
    Page 1 · response
    Published 1 July 2018

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Mohammad Ismaeel Ashraf · 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

    Mohammad Ismaeel Ashraf, a nine-year-old boy with multiple food allergies, suffered an anaphylactic reaction at school after eating lunch and died later that day following unsuccessful resuscitation. Concerns included failures and delays in care plans, ineffective communication about allergy information, unsafe allergy-identification lanyards, and failure to administer his epipen promptly despite his deteriorating condition.

    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 issued care plans to the food provider

    Wider context from the report

    “3. All issued care plans had not been provided to Caterlink by the school and communication between the school and Caterlink was not as effective as they could be. ”

    Source location

    Mohammad Ismaeel Ashraf · 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 rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.

    Verbatim wording from the response

    “The School was very concerned to hear the evidence given by the uncle of the deceased at the inquest that the Health Care Plan for Ismael’s sister was inaccurate. At the time of the inquest the pupils were on the six week summer holiday and so neither pupil nor any other pupils were being put at risk at the time the evidence came to light. The School took immediate steps, before the school re-opened in September 2017, to review and rectify any inaccuracies.”

    Source location

    2017-0243-Response-by-Al-Hijrah-School
    Page 2 · response
    Published 2 October 2017

    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

    Conduct routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.

    Verbatim wording from the response

    “The School has implemented a routine half termly check of all Health Care Plans displayed at key locations and held by the catering teams, which are cross checked against the master list held centrally at the school.”

    Source location

    2017-0243-Response-by-Al-Hijrah-School
    Page 2 · response
    Published 2 October 2017

    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 allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.

    Verbatim wording from the response

    “Aside from the monthly meetings the School has implemented a robust system to ensure that the catering staff are notified of any new allergy information as soon as the School is notified. The pupil is added to the pre-order list and a prepared lunch is provided to the pupil by the catering team. The pupil is accompanied to lunch by a member of staff. A record is kept of all notifications made to the catering team. The pupil is issued once a Health Care Plan has been issued by the School, which is signed by both the catering manager and a signed record kept of delivery and receipt of the Health Care Plan to the catering manager.”

    Source location

    2017-0243-Response-by-Al-Hijrah-School
    Page 5 · response
    Published 2 October 2017

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026