Concerns raised 5 Conflicting and undefined terminology in care plans and guidance View source Lack of understanding and training regarding care staff supervision and monitoring requirements View source Failure to apply professional curiosity when evaluating assumptions about service-user safety View source Absence of training to guard against confirmation bias in assessing enduring choking risk View source Inadequate staff confidence in emergency first aid for choking cases View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Craig Brendon SPIBY · 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
Craig Brendon SPIBY, who had a condition that made him susceptible to choking, died on 13 July 2024 after choking on a sandwich while eating lunch unsupervised at an assisted living facility. The principal concerns were inconsistent understanding and use of monitoring and supervision requirements, inadequate clarity in care-plan terminology, insufficient professional curiosity when he was believed to be asleep, limited confidence in choking-related first aid, and a lack of training addressing confirmation bias.
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 Bolton Cares; that does not assign responsibility.
PFD Monitor interpretation Conflicting and undefined terminology in care plans and guidance
Wider context from the report “The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018.
The Care and Support plan made clear that at mealtimes in particular, the deceased ought
to be ‘monitored’.
The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’.
Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times.
Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time.
Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial.
It follows that the following matters of specific concern arise:
1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user.
2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used.
3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe.
4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case.
5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events.
” 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 Bolton Cares; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding and training regarding care staff supervision and monitoring requirements
Wider context from the report “The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018.
The Care and Support plan made clear that at mealtimes in particular, the deceased ought
to be ‘monitored’.
The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’.
Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times.
Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time.
Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial.
It follows that the following matters of specific concern arise:
1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user.
2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used.
3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe.
4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case.
5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events.
” 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 Bolton Cares; that does not assign responsibility.
PFD Monitor interpretation Failure to apply professional curiosity when evaluating assumptions about service-user safety
Wider context from the report “The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018.
The Care and Support plan made clear that at mealtimes in particular, the deceased ought
to be ‘monitored’.
The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’.
Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times.
Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time.
Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial.
It follows that the following matters of specific concern arise:
1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user.
2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used.
3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe .
4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case.
5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events.
” 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 Bolton Cares; that does not assign responsibility.
PFD Monitor interpretation Absence of training to guard against confirmation bias in assessing enduring choking risk
Wider context from the report “The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018.
The Care and Support plan made clear that at mealtimes in particular, the deceased ought
to be ‘monitored’.
The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’.
Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times.
Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time.
Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial.
It follows that the following matters of specific concern arise:
1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user.
2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used.
3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe.
4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case.
5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events.
” 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 Bolton Cares; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff confidence in emergency first aid for choking cases
Wider context from the report “The deceased had an enduring risk of choking, especially at mealtimes, and was the subject of a Care and Support Plan; Bad Day Support Plan; Good Day Consistency and bespoke Eating and Drinking Guidelines that had been updated in 2018.
The Care and Support plan made clear that at mealtimes in particular, the deceased ought
to be ‘monitored’.
The Speech and Language Therapy guidance made clear that at mealtimes the deceased was to be ‘supervised’.
Managers gave evidence that their definition of ‘monitoring’ and ‘supervising’ was an expectation that the deceased would be kept in ‘line of sight’ at all times.
Care workers gave evidence that they were expected only to ‘monitor’ the deceased – which had the consequence of meaning they felt it appropriate to leave the deceased unsupervised but within earshot, in differing rooms of the care facility for short period of time.
Care workers also gave evidence to the effect that improvement to first aid training when dealing with a choking or aspiration emergency would be beneficial.
It follows that the following matters of specific concern arise:
1. A lack of understanding and/or training as to the specific requirements and expectations as to the role of care staff when supervising/monitoring a service user.
2. The confusion that arises in the existence differing language that applies in Care Plans and Guidance with no corresponding definition of the terms used.
3. How and why staff having assumed the deceased to have fallen asleep at a mealtime after a period of absence from the room, did not use more professional curiosity to evaluate whether such an assumption was correct or safe.
4. The lack of confidence expressed by staff in the emergency first aid training provided when responding in a choking case.
5. An absence of training to guard against confirmation bias with long term service users who have enduring high risk of choking, but with no actual previously recorded episodes of such events.
” 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 an electronic Read and Sign record requiring new staff to familiarise themselves with SALT guidelines immediately.
Verbatim wording from the response “Craig was diagnosed with Phelan McDermid Syndrome. This syndrome increases the risk of choking and aspiration. There had been no reported episodes of choking for many years, but the risk remained consistent. To address this, we have included a reminder of not becoming complacent within the toolbox talk described above and in addition to the SALT guidelines, which we currently complete, we have implemented an electronic ‘Read and Sign’ record. This will ensure that new staff members are required to familiarise themselves immediately.” Source location Response from Bolton Cares
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 Revise support plans to define supervision and monitoring terms used alongside SALT guidance.
Verbatim wording from the response “Once these amended guidelines are in place, we will ensure that the terms of use are reflected in our support plans.” Source location Response from Bolton Cares
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 refresher toolbox training requiring staff to remain physically present during supervision and check unusual behaviour, including when service users fall asleep.
Verbatim wording from the response “However, since the incident, we have provided refresher training to staff, by way of a toolbox talk, to confirm what is expected when a support worker is required to be supervising or monitoring. This reinforces to staff, that they must remain in the room and remain physically present with the supported person, keeping them under observation whilst they are undertaking the task for which they require supervising or monitoring for.” Source location Response from Bolton Cares
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 SALT guidelines to standard bi-monthly team meeting agendas to reinforce ongoing awareness of choking risk.
Verbatim wording from the response “We have also included ‘SALT guidelines’ on our standard Team Meeting agendas. These team meetings take place every two months and by including this on the agenda we are reminding staff team that the guidelines are in place and despite there being no incidents, the risk remains the same.” Source location Response from Bolton Cares
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 anti-choking devices and training on their use to every service supporting individuals with SALT guidelines.
Verbatim wording from the response “Since the incident we have provided every service that supports individuals with SALT guidelines with anti-choking devices and provided training on their use to put additional safeguards in place.” Source location Response from Bolton Cares
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 The incident reflected one worker’s departure from established guidance, rather than a wider staff training or understanding failure.
Verbatim wording from the response “Our internal investigation found that all support staff were aware of the choking risk posed by Craig, the measures in place to reduce this risk; including how his food was prepared and how he was then monitored and supervised whilst eating; and the care plans and SALT guidelines in place for him. The staff members who we spoke to were able to relay details from the guidelines during their interviews.” Source location Response from Bolton Cares
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 SALT professionals within Bolton Council are responsible for amending guideline terminology; support plans will reflect the amended terms.
Verbatim wording from the response “SALT (Speech and Language Therapy) guidelines and Eating and Drinking Guidance are provided by the Speech and Language Team from Bolton Community Learning Disability Team, Bolton Council. They do use the terms ‘supervise/monitor’ and these terms are then reflected in our own Provider Support Plans. Following receipt of the Coroner’s report we have worked with Bolton Council and the relevant health colleagues and adult social care teams to address these issues.” Source location Response from Bolton Cares
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 face-to-face first-aid training includes dedicated choking-response instruction and exceeds required standards.
Verbatim wording from the response “During our internal investigation into this matter, Bolton Cares considered the training provided to our workforce. All staff supporting Craig at the time of the incident had completed their mandatory First Aid training. In Bolton Cares Supported Living, we provide one day, face-to-face First Aid training which is accompanied by a face-to-face refresher training course every three years. The level of training provided is above the standards required. Online Training is considered an acceptable option, but we believe that face-to-face training is more effective and therefore provide this.” Source location Response from Bolton Cares
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations