PFD report

Mr Madhavbhai Khushalbhai Patel · Prevention of Future Deaths report

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Issued 14 Jan 2020•Black Country

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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 raised3

  1. Failure to advise families about eating with hands
  2. Failure to assess and advise on bread and bread products within dysphagia dietary guidance
    Part of recurring concern: Unreliable dysphagia care and management
  3. Failure to provide families with the IDDSI definition of ‘bite sized’
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and families
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.5

  1. Action

    Complete a clinical audit 90 days after launching the revised risk assessment documents.

    Stated by Walsall Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
  2. Action

    Review and revise the risk assessment and rating document to address patients’ eating methods, including eating with hands.

    Stated by Walsall Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
  3. Action

    Replace internally developed patient documents with IDDSI guidance covering food, fluids, portion sizes, bite sizes and transitional foods.

    Stated by Walsall Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.

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 advise families about eating with hands

Wider context from the report

“(1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm. (2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’. (3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’. (4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines. (5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands. The inquest did not find that any of the above matters were causative or contributory to death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 assess and advise on bread and bread products within dysphagia dietary guidance

Wider context from the report

“(1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm. (2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’. (3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’. (4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines. (5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands. The inquest did not find that any of the above matters were causative or contributory to death. ”

Is this part of a recurring concern?

Yes — Unreliable dysphagia care and management.

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 families with the IDDSI definition of ‘bite sized’

Wider context from the report

“(1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm. (2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’. (3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’. (4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines. (5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands. The inquest did not find that any of the above matters were causative or contributory to death. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families.

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

Complete a clinical audit 90 days after launching the revised risk assessment documents.

Verbatim wording from the response

“5. We will be reviewing and revising our risk assessment and rating document, to specifically include questions about and advice regarding the mode of eating by patients (including the use of hands) to ensure that suitable advice is given to patients who use methods other than forks. This will be achieved as part of the policy review identified above but we endeavor to launch this assessment tool in advance of the ratification of our revised policy. The implementation of these documents will be assured through the completion of a clinical audit 90 days following launch.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020

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 and revise the risk assessment and rating document to address patients’ eating methods, including eating with hands.

Verbatim wording from the response

“5. We will be reviewing and revising our risk assessment and rating document, to specifically include questions about and advice regarding the mode of eating by patients (including the use of hands) to ensure that suitable advice is given to patients who use methods other than forks. This will be achieved as part of the policy review identified above but we endeavor to launch this assessment tool in advance of the ratification of our revised policy. The implementation of these documents will be assured through the completion of a clinical audit 90 days following launch.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020

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 internally developed patient documents with IDDSI guidance covering food, fluids, portion sizes, bite sizes and transitional foods.

Verbatim wording from the response

“4. We will be replacing our current internally developed patient documents with those provided by IDDSI which provide clearer visual guidance to patients and their families / carers about the recommended food and fluid intake as well as the appropriate size of portions and the size of each bite. These documents also include specific reference to ‘transitional foods’, such as breads or similar products such as roti and chapatti, with guidance and an assessment criteria for their consumption. We aim to complete this transition on or before April 1st 2020.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020

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 and update the dysphagia policy to incorporate current IDDSI standards.

Verbatim wording from the response

“3. We will be reviewing and updating our dysphagia policy to fully incorporate the current IDDSI standards to ensure our delivery of care to patients in all settings is undertaken in adherence to these international best practice guidelines by June 2020.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Implement a staff checklist in patient records prompting and evidencing distribution of supportive and advisory documents.

Verbatim wording from the response

“6. A revised checklist for staff will be implemented to be included within patients records to assure that staff are prompted to handout all relevant supportive and advisory documents to patients and their family / carers and that this can be evidenced. This too will form part of a revised policy but we would anticipate this coming into use prior to the final ratification of the policy to ensure patients are supported.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

    Share the anonymised case and learning across the speech and language team.

    Stated by Walsall Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 February 2020.
  2. 2

    Re-establish a nutritional steering group to oversee patient nutrition and hydration planning and management.

    Stated by Walsall Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 February 2020.
  3. 3

    Continue enacting and sharing actions and lessons widely with staff across the organisation.

    Stated by Walsall Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 February 2020.

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

Share the anonymised case and learning across the speech and language team.

Verbatim wording from the response

“1. The case and its conclusion have been anonymized and shared across the speech and language team to ensure all colleagues have taken immediate learning from this incident to prevent recurrence.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Re-establish a nutritional steering group to oversee patient nutrition and hydration planning and management.

Verbatim wording from the response

“2. The Trust will be seeking to re-establish its nutritional steering group to support and oversee the planning and management for patient nutrition and hydration in the patient’s own home and acute hospital settings.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 2 · response
Published 8 February 2020

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

Continue enacting and sharing actions and lessons widely with staff across the organisation.

Verbatim wording from the response

“I would like to take the opportunity to assure you that as an organisation we have taken this case seriously and have and will continue to ensure actions and lessons from this are enacted and shared widely with staff across the organisation.”

Source location

2020-0006-Response-from-Walsall-NHS-Trust-Redacted
Page 1 · response
Published 8 February 2020

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