Coed Duon

Private and voluntary organisations · Residential care home

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First report 3 Jun 2019•Latest report 3 Jun 2019

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: 5
Stated actions: 10

Concerns and recipient responses

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

3 Jun2019
North Wales (East and Central)
Concerns raised5
1. Failure of staff to demonstrate understanding of safe food and fluid care and choking-risk management
2. Insufficient staff training in first aid and assisting residents at risk of choking
3. Inadequate management oversight of staff deployment for residents requiring choking-risk or one-to-one food and fluid assistance
1. Failure to intervene when an internal emergency alarm indicates assistance is needed
2. Insufficient staff training in selecting and preparing food and fluids for residents at risk of choking
Actions described in response 8
1. Action
  Provide a registered general nurse in the dining room throughout mealtimes.
2. Action
  Establish at least one qualified first aider on duty at all times.
3. Action
  Train new staff on SALT IDDS dysphagia procedures at the scheduled training session.
1. Action
  Establish two trained dysphagia champions to support staff training.
2. Action
  Provide trained mealtime staff in the dining room to oversee dysphagia-trained staff assisting residents at choking risk.
3. Action
  Maintain resident-specific diet and fluid consistency files, with staff acknowledgement of changes.
4. Action
  Train current staff in basic dysphagia awareness.
5. Action
  Teach new staff safe care for residents at choking risk and prohibit assistance before completing this training.
Respondent positions 3
1. Position
  Two staff members responded to the emergency call and there was no sign that the resident was in distress.
  Disputes the concern
1. Position
  There was no evidence that the aspirated food had not been prepared to a safe consistency.
  Disputes the concern
2. Position
  A registered general nurse is always present in the dining room during mealtimes.
  Existing arrangements considered sufficient
AI-generated summary

Kathleen Smith · 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

Kathleen Smith, who had advanced dementia and was at risk of choking, died after being fed unsuitable food and aspirating. The report raised concerns about inadequate staff training, failure to assist during the choking emergency, poor communication, and insufficient management oversight of safe food and fluid care.

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 Coed Duon; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to demonstrate understanding of safe food and fluid care and choking-risk management
Wider context from the report
“1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. ”
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 Coed Duon; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff training in first aid and assisting residents at risk of choking
Wider context from the report
“1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. ”
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 Coed Duon; that does not assign responsibility.
PFD Monitor interpretation
Inadequate management oversight of staff deployment for residents requiring choking-risk or one-to-one food and fluid assistance
Wider context from the report
“1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. ”
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 Coed Duon; that does not assign responsibility.
PFD Monitor interpretation
Failure to intervene when an internal emergency alarm indicates assistance is needed
Wider context from the report
“1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. ”
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 Coed Duon; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff training in selecting and preparing food and fluids for residents at risk of choking
Wider context from the report
“1. Staff were not sufficiently trained in first aid or how to assist a resident who was at risk of choking. 2. Staff did not intervene to assist the resident for whom the internal emergency alarm had been sounded as help was needed. 3. Staff were not sufficiently trained in how to select and prepare correct foods and fluids for residents with special dietary needs and who had a documented risk of choking. 4. The above training remains incomplete approximately 11 months after the death of Mrs Smith. 5. Staff could not demonstrate they understood how to deliver safe care and treatment regarding food and fluids and manage the risk of choking. 6. There is no adequate management oversight to ensure staff are appropriately deployed to those residents at risk of choking and or who require one to one assistance with food and fluids. ”
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
Provide a registered general nurse in the dining room throughout mealtimes.

Verbatim wording from the response
“6. There is always an RGN in the dining room during mealtimes.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
Establish at least one qualified first aider on duty at all times.

Verbatim wording from the response
“1a. You expressed concerns in your report regarding our lack of adequate first aiders. Since then I have, despite difficulty obtaining vacant slots, several members of staff on first aid courses. This now allows us to have at least one qualified First Aider on duty.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
Train new staff on SALT IDDS dysphagia procedures at the scheduled training session.

Verbatim wording from the response
“1b. All current staff have now been trained on basic awareness of Dysphagia. Also all new staff members have been booked on next available SALT (IDDS) training day which is on 6/08/19. We also now have 2 Dysphagia champions who have done the training for Dysphagia and who are now fully equipped to carry out to train all our staff.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
Establish two trained dysphagia champions to support staff training.

Verbatim wording from the response
“1b. All current staff have now been trained on basic awareness of Dysphagia. Also all new staff members have been booked on next available SALT (IDDS) training day which is on 6/08/19. We also now have 2 Dysphagia champions who have done the training for Dysphagia and who are now fully equipped to carry out to train all our staff.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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 trained mealtime staff in the dining room to oversee dysphagia-trained staff assisting residents at choking risk.

Verbatim wording from the response
“5. There is a trained member of staff on duty in the dining room during mealtimes to oversee the appropriately trained staff in Dysphagia to assist the residents at risk of choking. Also staff now write on diet & fluid charts what daily meals are served and they are clearer on what they have eaten, for example. puree mashed potatoes, puree, instead of Mash, Veg chicken”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
Maintain resident-specific diet and fluid consistency files, with staff acknowledgement of changes.

Verbatim wording from the response
“We have now set up a Diets and fluids consistency file for each resident, which have been graded by the exterior health professionals, this file is held in the kitchen and all the kitchen staff have been trained to be aware of its content. If any changes occur they are given a copy of these changes and all staff now sign to say they acknowledge if there are any changes to their diets.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
Train current staff in basic dysphagia awareness.

Verbatim wording from the response
“1b. All current staff have now been trained on basic awareness of Dysphagia. Also all new staff members have been booked on next available SALT (IDDS) training day which is on 6/08/19. We also now have 2 Dysphagia champions who have done the training for Dysphagia and who are now fully equipped to carry out to train all our staff.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
Teach new staff safe care for residents at choking risk and prohibit assistance before completing this training.

Verbatim wording from the response
“3. As part of their induction training all new staff members are taught how to deliver safe care in residents with a choking risk. We have also made it very clear to new staff that they are NOT allowed to assist residents at risk of choking until this training has been done.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
Two staff members responded to the emergency call and there was no sign that the resident was in distress.

Verbatim wording from the response
“2. On the day in question, I must once again stress that two members of staff answered the emergency nurse call bell, one was the duty RGN and the other a senior carer, they did intervene and carer remained with her until she passed away, there was no sign she was in distress.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
There was no evidence that the aspirated food had not been prepared to a safe consistency.

Verbatim wording from the response
“Nevertheless, in defence of my staff, Mrs Smith had been at the home for four weeks, during which time the staff had been regularly feeding her satisfactorily. On the day in question Mrs Smith’s carer, who incidentally had several years’ experience who was feeding her. From your report there appears to be no evidence that the food which she had aspirated had not been prepared to a proper safe consistency. As must have been done satisfactorily with no adverse effects on so many occasions before.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
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
A registered general nurse is always present in the dining room during mealtimes.

Verbatim wording from the response
“6. There is always an RGN in the dining room during mealtimes.”

Source location
2019-0184-Response-by-Coed-Duon-Care-Home
Page 2 · response
Published 14 August 2019
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure of staff to demonstrate understanding of safe food and fluid care and choking-risk management

Insufficient staff training in first aid and assisting residents at risk of choking

Inadequate management oversight of staff deployment for residents requiring choking-risk or one-to-one food and fluid assistance

Failure to intervene when an internal emergency alarm indicates assistance is needed

Insufficient staff training in selecting and preparing food and fluids for residents at risk of choking

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.8

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3

Actions described in response 8

Respondent positions 3