Recurring concern

Inadequate management of foreign-body ingestion risks

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First reported 1 Aug 2016•Latest report 14 May 2026

Definition

What this concern includes

Includes deficiencies in controls specifically dedicated to preventing, assessing, escalating or responding to suspected or recurrent ingestion of foreign bodies or non-food items.

Not included

Excludes generic risk-assessment deficiencies not tied to ingestion of foreign bodies or non-food items.
Excludes clinical investigation guidance for persistent symptoms after suspected ingestion unless it concerns the broader ingestion-risk management process.
Excludes unrelated self-harm, suicide, falls or other hazard-management concerns.

Reports: 5
Individual concerns: 10
Date range: 2016–2026
Stated actions: 22

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.

Care Quality Commission2

Coventry and Warwickshire Partnership NHS Trust1

Department of Health and Social Care1

Meade Close1

NHS Greater Manchester Integrated Care Board1

Nottinghamshire Healthcare NHS Foundation Trust1

Tees, Esk and Wear Valleys NHS Foundation Trust1

Trafford Borough Council1

University Hospitals Coventry and Warwickshire 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.

14 May2026
Coventry and Warwickshire
Concerns raised1
1. Failure to proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion
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 4
1. Action
  Conduct daily electronic environmental audits, address identified hazards, and escalate matters requiring Estates intervention.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
2. Action
  Implement a multidisciplinary, formulation-based safety and risk assessment framework that explicitly considers impulsivity and related risk factors.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
3. Action
  Provide training supporting formulation-based risk management, professional curiosity, multidisciplinary collaboration, and information triangulation.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
1. Action
  Monitor risk-assessment quality through ward management audits and additional Matron-led assurance audits using the AMaT system.
  Stated by Coventry and Warwickshire Partnership NHS TrustStated completed
AI-generated summary

Natalia Violet Cestaro (known as “Tali”) · 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

Natalia Violet Cestaro, known as “Tali”, was an 18-year-old inpatient who died on 15 November 2023 after ingesting a foreign object, undergoing endoscopic removal, and subsequently developing gastric perforation, sepsis and multi-organ failure. The principal concerns included the proactive assessment of risks from impulsive ingestion, liaison between mental health and acute services, and assurance and auditing of communication processes.

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 proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion
Wider context from the report
“a) Proactive scope of risk assessment for impulsive ingestion (CWPT) The evidence raised a concern that risk assessments may focus primarily on specific previously ingested items, rather than undertaking a sufficiently proactive assessment of a wider range of swallowable items within the inpatient environment. Where a patient is known to pose a persistent risk of impulsive ingestion, a predominantly reactive approach risks foreseeable hazards not being identified and mitigated in advance. ”
Source location
Natalia Violet Cestaro (known as “Tali”) · 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
Conduct daily electronic environmental audits, address identified hazards, and escalate matters requiring Estates intervention.

Verbatim wording from the response
“We will continue to undertake daily environmental audits across our mental health wards to identify, address and remove potential and foreseeable hazards. These audits are completed electronically, updated in real time and enable immediate escalation of environmental concerns requiring Estates intervention.”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 17 July 2026
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 multidisciplinary, formulation-based safety and risk assessment framework that explicitly considers impulsivity and related risk factors.

Verbatim wording from the response
“Our safety (risk) assessment, formulation and planning framework has undergone multidisciplinary review to ensure alignment with National Institute for Health and Care Excellence (NICE) Guideline NG225. The framework incorporates a formulation-based approach that considers factors which may predispose individuals to unsafe behaviours, perpetuate risk, or act as protective influences. Impulsivity is specifically considered within this formulation process.”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 17 July 2026
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 training supporting formulation-based risk management, professional curiosity, multidisciplinary collaboration, and information triangulation.

Verbatim wording from the response
“Our training programme supports this formulation-based approach to safety and risk management, with a strong emphasis on professional curiosity, multidisciplinary collaboration and triangulation of information obtained from those important to the individual and those involved in their care. The training encourages staff to consider a broader range of factors that may influence safety and wellbeing and supports a move away from historical documentation and approaches, such as the Skills-based Training on Risk Management (STORM) and Working with Risk (WWR) tools.”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 17 July 2026
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
Monitor risk-assessment quality through ward management audits and additional Matron-led assurance audits using the AMaT system.

Verbatim wording from the response
“The quality of risk assessments is routinely monitored through our Audit Management and Tracking (AMaT) system. Audits are undertaken by ward management teams, with additional assurance provided through separate Matron-led audits.”

Source location
Response from Coventry and Warwickshire Partnership NHS Trust
Page 2 · response
Published 17 July 2026
Open published response
5 Jan2024
Nottinghamshire
Concerns raised5
1. Lack of policy specifying where foreign-body ingestion risk assessments are stored
2. Lack of policy for managing suspected foreign-body ingestion medically
3. Lack of policy for assessing ingestion risk when access to risk items is permitted
1. Lack of policy specifying responsibility for reviewing foreign-body ingestion risk assessment content
2. Lack of policy for security measures to locate ingested foreign bodies
This report raised 7 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 4
1. Action
  Review and update the foreign-body ingestion management procedure, including a bespoke care-plan framework for patients at clinical risk.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Obtain ratification of the revised foreign-body ingestion policy and additions through the Trust Clinical Policies approval group.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
3. Action
  Disseminate the ratified foreign-body ingestion policy to all areas where that risk is present.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
1. Action
  Undertake case reviews of subsequent similar presentations to assess whether learning from the death is embedded and sustained.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
AI-generated summary

Tammy Mary Louise WATKINS · 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

Tammy Mary Louise Watkins died on 6 June 2021 after swallowing a plastic twistable crayon that perforated her bowel while she was detained at Rampton Hospital. The principal concerns were failures to risk-assess and manage foreign-body ingestion, recognise and escalate her deteriorating condition, follow NEWS2 requirements, and coordinate an emergency transfer to hospital. The report also identifies poor-quality acute physical healthcare and confusion about emergency medical calls.

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 policy specifying where foreign-body ingestion risk assessments are stored
Wider context from the report
“3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. ”
Source location
Tammy Mary Louise WATKINS · Prevention of Future Deaths report
Page 3 · 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 policy for managing suspected foreign-body ingestion medically
Wider context from the report
“3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. ”
Source location
Tammy Mary Louise WATKINS · Prevention of Future Deaths report
Page 3 · 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 policy for assessing ingestion risk when access to risk items is permitted
Wider context from the report
“3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. ”
Source location
Tammy Mary Louise WATKINS · Prevention of Future Deaths report
Page 3 · 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 policy specifying responsibility for reviewing foreign-body ingestion risk assessment content
Wider context from the report
“3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. ”
Source location
Tammy Mary Louise WATKINS · Prevention of Future Deaths report
Page 3 · 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 policy for security measures to locate ingested foreign bodies
Wider context from the report
“3. A lack of robust policy relating to Ingestion of Foreign Bodies I heard evidence that the Trust is in the process of drafting a policy, but it became clear during evidence that the policy is not yet sufficiently robust. The policy needs to cover the assessment of risk when access is permitted to risk items, where such a risk assessment is stored and who is responsible for its review of content, what to do when ingestion is suspected including how this should be managed medically and what security measures need to be taken to locate the item. ”
Source location
Tammy Mary Louise WATKINS · 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
Review and update the foreign-body ingestion management procedure, including a bespoke care-plan framework for patients at clinical risk.

Verbatim wording from the response
“3. A lack of robust policy relating to Ingestion of Foreign Bodies The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 19 January 2024
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
Obtain ratification of the revised foreign-body ingestion policy and additions through the Trust Clinical Policies approval group.

Verbatim wording from the response
“3. A lack of robust policy relating to Ingestion of Foreign Bodies The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 19 January 2024
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
Disseminate the ratified foreign-body ingestion policy to all areas where that risk is present.

Verbatim wording from the response
“3. A lack of robust policy relating to Ingestion of Foreign Bodies The procedure for the management of patients who have ingested foreign bodies has been reviewed and updated following the death of Tammy. There is a focus to implement a bespoke care plan for patients who present a clinical risk of ingestion with a clear framework of how to act should this clinical incident occur. The revised policy with these additions are for ratification at the Trust Clinical Policies approval group 6 March 2024. This will then be widely disseminated to all areas whereby the risk of ingestion of foreign bodies is present.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 19 January 2024
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
Undertake case reviews of subsequent similar presentations to assess whether learning from the death is embedded and sustained.

Verbatim wording from the response
“To review current practice and to continue to address areas of concern, Rampton Hospital are undertaking case reviews of subsequent similar presentations to identify if the learning from Tammy’s death has been embedded and sustained. We will ensure that any learning or areas for continued training are identified within these case reviews are responded to and included within Hospital Life Support training/ any future enhanced training that is provided.”

Source location
Response from Nottinghamshire Healthcare NHS Foundation Trust
Page 3 · response
Published 19 January 2024
Open published response
24 Apr2020
Manchester South
Concerns raised1
1. Failure to document and risk assess observed mouthing of foreign non-food items
This report raised 5 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 3
1. Position
  Existing risk-management arrangements and the action plan’s handover, communication, and assessment processes were considered to address known choking and non-food-item risks.
  Stated by Care Quality CommissionExisting arrangements considered sufficient
1. Position
  Existing CQC regulatory action and continued monitoring are considered sufficient to reduce further risks at the care home.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
2. Position
  Registered providers and service managers are responsible for safe care, local risk assessments and mitigating environmental and other risks.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Mary Brady · 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

Mary Brady, who had vascular dementia and lived in a care home, was found unresponsive after being left unobserved in a communal area. A used pair of latex gloves was removed from her airway, and she died shortly after midnight on 11 March 2019. Concerns included accessible open waste baskets, improper disposal and insufficient escalation of used gloves, and failures to document and risk-assess her previous ingestion of non-food items or update her care plan.

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 document and risk assess observed mouthing of foreign non-food items
Wider context from the report
“3. Mrs Brady had been seen putting foreign non-food items in her mouth by staff. These instances had not been appropriately documented and risk assessed. The level of risk she presented was not fully understood as a result and her care plan was not updated. ”
Source location
Mary Brady · Prevention of Future Deaths report
Page 3 · 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
Existing risk-management arrangements and the action plan’s handover, communication, and assessment processes were considered to address known choking and non-food-item risks.

Verbatim wording from the response
“The CQC is satisfied that appropriate steps have been taken to ensure that staff recognise risks from choking and document them appropriately. This is based on our previous knowledge of this location, how they have responded to this incident and the input from Tameside Local Authority in developing an action plan.”

Source location
2020-0105-Response-from-Care-Quality-Commission_Redacted-1.pdf
Page 6 · response
Published 5 June 2020
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
Existing CQC regulatory action and continued monitoring are considered sufficient to reduce further risks at the care home.

Verbatim wording from the response
“You issued your report to the Care Quality Commission (CQC) and Departmental officials have made enquiries with the CQC on the regulatory activity in relation to this incident. I am therefore aware that following a review of the circumstances of Mrs Brady’s death; information provided by the registered provider and the action it has taken; and the findings of a CQC inspection conducted in February 2019, the CQC is satisfied that sufficient action has been taken to reduce further risks within the Balmoral Care Home and that there was insufficient evidence that a breach of the Regulations¹ had occurred. The CQC’s response to your report provides further detail on its considerations in relation to this case.”

Source location
2020-0105-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 1 · response
Published 5 June 2020
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
Registered providers and service managers are responsible for safe care, local risk assessments and mitigating environmental and other risks.

Verbatim wording from the response
“Registered providers and managers of services are expected to ensure they are delivering care safely and doing all they can to mitigate risks through the conduct of local risk assessments (including for example, assessing environmental risks such as those associated with open wastebaskets). Providers are expected to plan care in line with good practice standards, such as guidance issued by the National Institute for Health and Care Excellence (NICE), and relevant professional and regulatory bodies.”

Source location
2020-0105-Response-from-the-Department-of-Health-and-Social-Care.pdf
Page 2 · response
Published 5 June 2020
Open published response
10 Feb2020
Manchester South
Concerns raised2
1. Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
2. Failure to restrict access to gloves for residents who may place items in their mouths
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 11
1. Action
  Reiterate that identified or reported risks must be incorporated into care plans and escalated to registered managers for appropriate risk assessment.
  Stated by Trafford Borough CouncilStated completed
2. Action
  Check the provider’s regulatory compliance at the next service inspection and require improvements or highlight breaches where warranted.
  Stated by Care Quality CommissionStated planned
3. Action
  Continue using enforcement powers to require improvements when providers are not meeting regulatory requirements.
  Stated by Care Quality CommissionStated in progress
1. Action
  Provide enhanced one-to-one supervision to the Support Worker on reporting and escalating incidents.
  Stated by Meade CloseStated completed
2. Action
  Hold a staff meeting addressing the risks of failing to report and record incidents.
  Stated by Meade CloseStated completed
3. Action
  Deliver a reporting and recording training reset for all staff.
  Stated by Meade CloseStated planned
4. Action
  Require all staff to retake the Reporting and Recording e-learning module.
  Stated by Meade CloseStated planned
5. Action
  Provide staff refresher training on key working, capacity, support planning, risk assessment, choking, recording, reporting, first aid and induction.
  Stated by Meade CloseStated planned
6. Action
  Deliver additional staff training on risk identification, escalation, safeguarding, basic life support, first aid and incident reporting.
  Stated by Meade CloseStated completed
7. Action
  Consult care providers on practical arrangements for safely storing gloves while preserving rapid access for clinical needs.
  Stated by Trafford Borough CouncilStated completed
8. Action
  Carry out resident-specific risk assessments covering glove location, access and associated risks, and communicate outcomes to staff.
  Stated by Meade CloseStated completed
AI-generated summary

Christine Rosemary Neild · 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

Christine Rosemary Neild had significant learning difficulties, dysphagia, and required feeding support. She became very unwell and died at Meade Close on 31 January 2020; the medical cause of death was a sub-acute bowel obstruction associated with an incisional hernia. Concerns included accessible gloves and other non-food items, a failure to escalate an earlier ingestion incident or undertake further risk assessment, and the lack of regular sensors to alert staff when residents got up at night.

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 escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment
Wider context from the report
“2. There had been an earlier incident when Christine Neild had put non-food items in her mouth. The carer did not escalate this and there was no further risk assessment. ”
Source location
Christine Rosemary Neild · 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 restrict access to gloves for residents who may place items in their mouths
Wider context from the report
“1. During the course of the inquest evidence was heard that gloves were in open and easily accessible locations throughout the home including in rooms and the kitchen area. The inquest was told that this is standard practice in care settings for people with learning disabilities even where residents do not have insight into what items can safely be placed in their mouths. ”
Source location
Christine Rosemary Neild · 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
Reiterate that identified or reported risks must be incorporated into care plans and escalated to registered managers for appropriate risk assessment.

Verbatim wording from the response
“We have re-iterated to our providers, the importance that where any identified/reported need (from any source) is to be incorporated into the person’s care delivery plan and escalated to the Registered Manager of the service. This will ensure that a risk assessment can be completed (where appropriate to do so) and those providing the care are aware of the person’s support needs and can record any observations through established recording and incident reporting mechanisms.”

Source location
2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 2 · response
Published 26 November 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
Check the provider’s regulatory compliance at the next service inspection and require improvements or highlight breaches where warranted.

Verbatim wording from the response
“We will check the provider’s compliance with the regulations on our next inspection of the service using our key lines of enquiry and in accordance with CQC’s”

Source location
2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 5 · response
Published 26 November 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
Continue using enforcement powers to require improvements when providers are not meeting regulatory requirements.

Verbatim wording from the response
“Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Miss Christine Neild with inspectors and registered persons.”

Source location
2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 6 · response
Published 26 November 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
Provide enhanced one-to-one supervision to the Support Worker on reporting and escalating incidents.

Verbatim wording from the response
“1. Enhanced one to one supervision has been undertaken with the Support Worker involved in the incident when Christine placed a non-food item in her mouth. It is accepted that the Support Worker did not report or record the incident. During the supervision session, the details of the incident were discussed and the importance of reporting incidents of this nature. The Support Worker said that she was aware of the importance of reporting and the reasons why she should. She accepted that in no reporting the incident meant that the incident was not escalated and a risk assessment was not carried out. She is aware of the consequences of not reporting such matters. She was disappointed in herself that she had not done so.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 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
Hold a staff meeting addressing the risks of failing to report and record incidents.

Verbatim wording from the response
“2. A staff meeting has taken place to discuss the issues raised by this case and specifically the risks of not reporting and recording incidents. It was agreed that all staff would have a recording and reporting training reset.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 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
Deliver a reporting and recording training reset for all staff.

Verbatim wording from the response
“2. A staff meeting has taken place to discuss the issues raised by this case and specifically the risks of not reporting and recording incidents. It was agreed that all staff would have a recording and reporting training reset.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 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
Require all staff to retake the Reporting and Recording e-learning module.

Verbatim wording from the response
“4. All staff members have undertaken a Reporting and Recording e-learning module however as a result of the issues raised by this case all staff are required to retake the Reporting and Recording e-learning module to refresh their memories and make sure that their learning is up to date.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 2 · response
Published 26 November 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
Provide staff refresher training on key working, capacity, support planning, risk assessment, choking, recording, reporting, first aid and induction.

Verbatim wording from the response
“discussions took place in respect of staff training and induction. It was agreed that all staff are to undertake refresher training in respect of Key working, Mental Capacity Act, Support planning/risk assessment, choking, recording and reporting, first aid and inductions. We attach a table detailing the actions agreed during the meeting.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 3 · response
Published 26 November 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
Deliver additional staff training on risk identification, escalation, safeguarding, basic life support, first aid and incident reporting.

Verbatim wording from the response
“However, as a result of the issues raised by the Coroner in this case, and as a reminder of the reporting and recording requirements, all staff members have received additional training with regards to identifying risks and then reporting and escalating the concerns in the appropriate way. All staff members have received training in respect of safeguarding adults and children, basic life support, first aid and reporting and recording of incidents.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 3 · response
Published 26 November 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
Consult care providers on practical arrangements for safely storing gloves while preserving rapid access for clinical needs.

Verbatim wording from the response
“As you are of course aware, the use of PPE is fundamental to ensure the health and safety of all of our residents during the pandemic and needs to be accessible at all times. We have consulted with our providers to see how we can pragmatically manage the safe storage of gloves in particular.”

Source location
2020-0192-Responses-from-Trafford-Council-and-CQC_Redacted.pdf
Page 2 · response
Published 26 November 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
Carry out resident-specific risk assessments covering glove location, access and associated risks, and communicate outcomes to staff.

Verbatim wording from the response
“8. We have carried out risk assessments for each resident, specifically in relation to the location of gloves, their access to them and any associate risk. For each resident we have considered the location of the gloves, both in communal areas and their personal bedroom and any risks that present for the individual resident. We assessed the precautions that are already in place and any further steps that need to be taken. A copy of the risk assessment has been placed in the individual residents Care Plan and the outcomes of the assessments have been communicated to all staff members. We will review the risk assessment every six months as a minimum or if an issue arises that prompts an earlier review this will be carried out immediately.”

Source location
2020-0192-Response-from-Meade-Close-Care-Home_Redacted.pdf
Page 3 · response
Published 26 November 2020
Open published response
1 Aug2016
County Durham and Darlington
Concerns raised1
1. Failure to consider physical effects of ingested foreign bodies and their link to abdominal pain
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 3
1. Action
  Review the observation and engagement procedure to consider enhanced observations after foreign-object ingestion.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
2. Action
  Deliver formal training on delayed physical effects, stool checks, risk and intervention plans, and recording related observations.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated planned
3. Action
  Work with the local Emergency Department to design and share standard work requiring thorax and abdominal X-rays in relevant cases.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated planned
AI-generated summary

Pamela Gressman · 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

Pamela Gressman died following the ingestion of foreign bodies, one or more of which led to a perforation of the colon; the inquest recorded hospital-acquired pneumonia as the medical cause of death. The report raised concern that insufficient consideration was given to the possible physical effects of the ingested objects and that there was no clear treatment and observation plan.

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 consider physical effects of ingested foreign bodies and their link to abdominal pain
Wider context from the report
“Whilst it is clear that considerable attention was given to the deceased’s mental health, insufficient consideration or no consideration was given to any physical effects which might ensue from her ingesting the foreign bodies that she reported she had and which led to her period of hospitalisation. Thus little or no thought was given to any link between such items and her presentation with abdominal pain in January 2016. The absence of a clear treatment and observation plan in such circumstances could lead to a risk of similar fatalities in the future. ”
Source location
Pamela Gressman · 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
Review the observation and engagement procedure to consider enhanced observations after foreign-object ingestion.

Verbatim wording from the response
“• A review of the observation and engagement procedure will include consideration of a period of enhanced observations for a period of time following ingestion of a foreign object to enable close monitoring of any physical side effects but also to monitor if any foreign bodies are passed through stools. Completed”

Source location
2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-NHS-Trust
Page 2 · response
Published 1 August 2016
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
Deliver formal training on delayed physical effects, stool checks, risk and intervention plans, and recording related observations.

Verbatim wording from the response
“• Formal training sessions to be delivered to specifically include: ◦ Consideration of the possibility of physical effects (sometimes delayed for days) following swallowing of foreign objects, in particular for patients with known history of this ◦ Clarification of process to check if foreign bodies have been passed in stools by patient ◦ The requirement to have a risk management plan and intervention plan to monitor and manage physical health care symptoms of concern and the need to record related observations (10 case notes to be audited). To be completed 31st October 2016 (delayed due to the challenges of delivering training during the holiday period).”

Source location
2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-NHS-Trust
Page 2 · response
Published 1 August 2016
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
Work with the local Emergency Department to design and share standard work requiring thorax and abdominal X-rays in relevant cases.

Verbatim wording from the response
“• Liaison colleagues to work with the local Emergency Department to ensure standard work is designed and shared to ensure X-rays are done of thorax and abdomen in such instances. To be completed by 31st October 2016.”

Source location
2016-0279-Response-by-Tees-Esk-amd-Water-Valleys-NHS-Trust
Page 2 · response
Published 1 August 2016
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to proactively assess a wider range of swallowable items for patients at persistent risk of impulsive ingestion

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.4

Concerns raised5

Lack of policy specifying where foreign-body ingestion risk assessments are stored

Lack of policy for managing suspected foreign-body ingestion medically

Lack of policy for assessing ingestion risk when access to risk items is permitted

Lack of policy specifying responsibility for reviewing foreign-body ingestion risk assessment content

Lack of policy for security measures to locate ingested foreign bodies

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.4

Concerns raised1

Failure to document and risk assess observed mouthing of foreign non-food items

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised2

Failure to escalate incidents involving residents putting non-food items in their mouths and undertake further risk assessment

Failure to restrict access to gloves for residents who may place items in their mouths

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.11

Actions described in response 4

Actions described in response 4

Respondent positions 3

Actions described in response 11