PFD report

Madeline Reding · Prevention of Future Deaths report

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Issued 21 Jul 2025•East London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
8

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
10

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised8

  1. Delayed and disorganised staff responses to developing emergencies
    Part of recurring concern: Failure of emergency response leadership and coordination
  2. Failure to attempt abdominal thrusts for choking
    Part of recurring concern: Unsafe implementation of choking-risk prevention measures
  3. Failure to commence CPR promptly when indicated despite a DNACPR order
    Part of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Action

    Engage an external provider to assess choking competency individually for all 73 permanent and agency staff.

    Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
  2. Action

    Display a colour-coded choking flow chart in nursing stations and pictorial choking first-aid posters in dining areas.

    Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
  3. Action

    Review the Swallowing Difficulties and Basic Life Support, Resuscitation and DNARCPR policies for compliance with relevant guidance.

    Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure of emergency response leadership and coordination.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unsafe implementation of choking-risk prevention measures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable resuscitation preparedness and response during cardiac arrest.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure of emergency alarm response.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unsafe implementation of choking-risk prevention measures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to initiate 999 calls promptly when life is at risk; Unreliable emergency response to patient collapse.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure of emergency response leadership and coordination.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to reliably respond to patient breathing emergencies; Unreliable resuscitation preparedness and response during cardiac arrest.

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

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Purchase and locate a defibrillator in the Manager’s office, with dining-area signage and staff guidance on its use.

    Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
  2. 2

    Require mandatory LifeVac and Basic First Aid training before new staff work with residents, with annual refresher training and compliance tracking.

    Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.
  3. 3

    Provide choking training to all staff every six months, regardless of role or employment status.

    Stated by Aspray HouseStated completedThe respondent said that this action was complete when they made their response on 23 July 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing monitoring, supervision, training and implemented changes are considered sufficient to keep residents safe and mitigate recurrence risk.

    Stated by Aspray HouseExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 locate a defibrillator in the Manager’s office, with dining-area signage and staff guidance on its use.

Verbatim wording from the response

“Aspray House also purchased its own defibrillator on 22 May 2025 which is located within the Manager’s office on the first floor of the Home. Posters displaying its location are displayed beside the Choking First Aid poster in all dining areas with all staff having been given guidance on its use.”

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

Require mandatory LifeVac and Basic First Aid training before new staff work with residents, with annual refresher training and compliance tracking.

Verbatim wording from the response

“Policies were already in place prior to the incident in respect of Swallowing Difficulties and Basic Life support, Resuscitation and DNARCPR which were not followed by the staff. These policies included instructions to dial 999, to give up to five back slaps followed by up to five abdominal thrusts, commence CPR if unresponsive, and use de-choking equipment (if trained). Additionally, all nursing and care staff were required to undertake annual First Aid Practical training and annual training on how and when to the use of Life-Vac de-choker equipment in choking situations.”

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

Provide choking training to all staff every six months, regardless of role or employment status.

Verbatim wording from the response

“All staff are now given choking training on a 6-monthly basis regardless of their role (including agency staff) – whether they be nurses, carers, cooks, housekeepers, maintenance staff etc.”

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 position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing monitoring, supervision, training and implemented changes are considered sufficient to keep residents safe and mitigate recurrence risk.

Verbatim wording from the response

“Mindful of the changes that we have implemented above, and which will be continuously monitored and reviewed going forward, we believe that all our residents are appropriately monitored, particularly dementia patients during mealtimes who are not left unattended and are closely supervised, and that the environment that they live in is safe with staff trained to a high standard.”

Source location

2025-0368 Response from Aspray House Nursing Home
Page 4 · response
Published 23 July 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026