Recipient

Aspray House LtdIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 11 May 2018•Latest report 11 May 2018

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
1

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found
1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Aspray House Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: ████████ Operational Director, Twinglobe Care Homes Ltd.

    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. The report was sent to Aspray House Ltd; that does not assign responsibility.

    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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Aspray House Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain robust systems for protecting patients at risk of choking, including checking food

    Wider context from the report

    “(1) The evidence given by the nursing staff and care staff who continue to work in the Care Home did not indicate a full understanding of the gravity of the risk of choking. Matters such as not causing offence to visitors or concern of turning the Home into a prison were quoted as reasons why food might not be fully checked. Care staff did not appear to appreciate that where a patient is at risk of choking, robust systems need to be in place to protect their lives. ”
    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
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026