Aspray House

Private and voluntary organisations · Residential care home

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First report 21 Jul 2025•Latest report 21 Jul 2025

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 100%
Concerns addressed: 7
Stated actions: 10

Concerns and recipient responses

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

21 Jul2025
East London
Concerns raised8
1. Delayed and disorganised staff responses to developing emergencies
2. Failure to attempt abdominal thrusts for choking
3. Failure to commence CPR promptly when indicated despite a DNACPR order
1. Failure to sound emergency alarms promptly
2. Failure to administer effective back slaps for choking
3. Failure to make 999 calls immediately on discovering an unresponsive person
4. Failure to provide effective leadership of emergency responses
5. Failure to commence chest compressions promptly after breathing stops
Actions described in response 7
1. Action
  Engage an external provider to assess choking competency individually for all 73 permanent and agency staff.
2. Action
  Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.
3. Action
  Review the Swallowing Difficulties and Basic Life Support, Resuscitation and DNARCPR policies for compliance with relevant guidance.
1. Action
  Purchase and use an Act Fast anti-choking trainer vest for practical training in back slaps and abdominal thrusts.
2. Action
  Deliver lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.
3. Action
  Add dementia-related choking-risk and CPR warnings to the Care Notes of every resident with a dementia diagnosis.
4. Action
  Replace the Home Manager and Deputy Operations Manager involved in the incident with new management.
AI-generated summary

Madeline Reding · 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

Madeline Reding, a 79-year-old nursing-home resident with advanced vascular dementia, became unwell after lunch on 17 May 2024, regurgitated food, developed an upper-airway obstruction and respiratory arrest, and died that afternoon. The inquest identified delayed and disorganised staff responses, including a failure to sound the emergency alarm or make an immediate 999 call, delayed CPR, and ineffective first aid.

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; that does not assign responsibility.
PFD Monitor interpretation
Delayed and disorganised staff responses to developing emergencies
Wider context from the report
“1. The inquest found that staff responses to the developing emergency were delayed and disorganised. Despite four registered nurses being present at the scene, no effective leadership of the emergency response was witnessed. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to attempt abdominal thrusts for choking
Wider context from the report
“5. First aid that was administered was ineffective. a. Back slaps were weak b. Abdominal thrusts were not attempted c. Chest compressions were only commenced over ten minutes after Mrs Reding was found to have stopped breathing. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to commence CPR promptly when indicated despite a DNACPR order
Wider context from the report
“4. Despite specific instructions to commence CPR being given on three separate occasions by a London Ambulance Service call dispatch handler, resuscitation was not commenced by a registered nurse as she did not appreciate that a “Do not attempt cardio-pulmonary resuscitation order” would not apply to the patient in the event that the cardiac arrest was due to a reversible cause, such as choking. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to sound emergency alarms promptly
Wider context from the report
“2. An emergency alarm was not sounded promptly. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to administer effective back slaps for choking
Wider context from the report
“5. First aid that was administered was ineffective. a. Back slaps were weak b. Abdominal thrusts were not attempted c. Chest compressions were only commenced over ten minutes after Mrs Reding was found to have stopped breathing. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to make 999 calls immediately on discovering an unresponsive person
Wider context from the report
“3. A 999 call was not made immediately on discovering Mrs Reding was unresponsive. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide effective leadership of emergency responses
Wider context from the report
“1. The inquest found that staff responses to the developing emergency were delayed and disorganised. Despite four registered nurses being present at the scene, no effective leadership of the emergency response was witnessed. ”
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; that does not assign responsibility.
PFD Monitor interpretation
Failure to commence chest compressions promptly after breathing stops
Wider context from the report
“5. First aid that was administered was ineffective. a. Back slaps were weak b. Abdominal thrusts were not attempted c. Chest compressions were only commenced over ten minutes after Mrs Reding was found to have stopped breathing. ”
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
Engage an external provider to assess choking competency individually for all 73 permanent and agency staff.

Verbatim wording from the response
“Following a subsequent meeting with the Local Authority and taking on board its concerns that all post-incident training competences and assessments were conducted in-house, Aspray House also engaged a private training provider – Michael Hughes Training - to assess its staffs’ competency in choking training. This training was undertaken on a two-day rotation on 21 and 31 March 2025 with individual assessments conducted with all 73 staff members working at the home (both permanent and agency staff). We confirm that all staff members successfully passed the course.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 3 · response
Published 23 July 2025
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
Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.

Verbatim wording from the response
“Senior management designed a simple to follow colour coded Choking Flow Chart in October 2024 which is compliant with current guidance and which has been placed on display in all nursing stations throughout Aspray House reinforcing the policy, procedure and expectations of how all staff should deal with choking situations – including highlighting that CPR must be attempted if suitable even on residents with a DNAR in place. This has been supplemented with a pictorial Choking First Aid poster for universal understanding which has been displayed in all dining areas.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
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
Review the Swallowing Difficulties and Basic Life Support, Resuscitation and DNARCPR policies for compliance with relevant guidance.

Verbatim wording from the response
“Immediately following the incident, an urgent flash Lessons Learnt training session was held with all nursing staff (including the management nurses present at the incident) on 23 May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, Resuscitation and DNARCPR policies and the procedures to be followed in the event of a choking incident. Both policies were subsequently reviewed on 31 July 2024 and noted to be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
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
Purchase and use an Act Fast anti-choking trainer vest for practical training in back slaps and abdominal thrusts.

Verbatim wording from the response
“In October 2024, Aspray House also purchased an Act Fast Anti Choking Trainer Vest for use in practical training to ensure that all staff are proficient in back slaps and abdominal thrusts. Students wear the Choking Vest to learn the correct manoeuvres which when performed correctly shoots a foam plug into the air. It also includes a foam back slap pad for practicing effective back slaps. Thus, making instruction realistic and leaving participants confident in their actions and their response to a genuine choking incident should one occur.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
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 lessons-learned, anti-choking, first-aid and competency training to permanent, agency, care and non-care staff, including refresher training.

Verbatim wording from the response
“Immediately following the incident, an urgent flash Lessons Learnt training session was held with all nursing staff (including the management nurses present at the incident) on 23 May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, Resuscitation and DNARCPR policies and the procedures to be followed in the event of a choking incident. Both policies were subsequently reviewed on 31 July 2024 and noted to be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
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 dementia-related choking-risk and CPR warnings to the Care Notes of every resident with a dementia diagnosis.

Verbatim wording from the response
“Aspray House noted the Coroner’s concerns at the Inquest that even where a choking risk assessment had been carried out and a resident not identified as having a choking risk, that a diagnosis of dementia could cause a risk of choking. Immediately after the inquest concluded, Aspray House implemented warnings being added to the Care Plans for every resident with a dementia diagnosis the following day. This new warning is displayed on the first page of a patient’s Care Notes on the hand-held PCS devices used by all staff and highlights a risk of choking (regardless of the score achieved against a standard choking risk assessment) due to dementia and that choking is a potentially reversible situation and that CPR should be commenced if suitable.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 3 · response
Published 23 July 2025
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
Replace the Home Manager and Deputy Operations Manager involved in the incident with new management.

Verbatim wording from the response
“The two Duty Lead nurses involved, along with all permanent and agency staff who work at Aspray House have been given extensive training (which we will address in further detail below), whilst the Home Manager and Deputy Operations Manager employed at the time who were involved in the incident (who were also registered nurses at that time) have been replaced with new management.”

Source location
2025-0368 Response from Aspray House Nursing Home
Page 2 · response
Published 23 July 2025
Open published response