MICHAEL DUNDON · Prevention of Future Deaths report

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Issued 23 Aug 2016•West Yorkshire Eastern

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

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 raised1

  1. Lack of staff awareness of the ingestion hazards of liquid-absorbing crystals

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

  1. Department of Health and Social Care

    Update the coroner as the matter progresses.

  2. Department of Health and Social Care

    Liaise with the Care Quality Commission to distribute resulting advice or guidance to care homes and hospices.

  3. Department of Health and Social Care

    Follow up the wider safety risks of the crystals with the Health and Safety Executive.

  4. Department of Health and Social Care

    Consider warning staff about the choking risk and the need for risk assessment.

  5. Department of Health and Social Care

    Explore safer alternatives or alternative uses for the solidifying crystals while preserving infection-control and patient-comfort benefits.

  6. Department of Health and Social Care

    Identify an effective method of reducing the choking risk from solidifying crystals.

  7. Department of Health and Social Care

    Notify providers of NHS-funded care once the most effective choking-hazard controls are identified.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Department of Health and Social Care

    Patient safety leadership and the response to this concern lie with NHS Improvement rather than the Department of Health.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. Department of Health and Social Care

    A warning may have limited effect, while a blanket restriction could cause patient harm and undermine infection control, comfort and dignity.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Lack of staff awareness of the ingestion hazards of liquid-absorbing crystals

Wider context from the report

“(3) The crystals had been pre-inserted into two empty urine bottles in the deceased’s room. The staff did not recognise that such sachets could be hazardous when left in this way. The deceased was able, whilst unsupervised, to swallow crystals, causing a cardiorespiratory arrest and death. (4) The risks associated with the use of these crystals may not be fully understood. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Update the coroner as the matter progresses.

Verbatim wording from the response

“I hope this information is helpful. NHS Improvement has undertaken to update you as it takes this matter forward and I have asked that my officials are kept informed of developments. Thank you for bringing the circumstances of Mr Dundon’s death to our attention.”

Source location

2016-0305-Response-by-Department-of-Health
Page 3 · response
Published 23 August 2016

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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

Liaise with the Care Quality Commission to distribute resulting advice or guidance to care homes and hospices.

Verbatim wording from the response

“Once NHS Improvement has identified the most effective way of managing the choking hazard while ensuring infection control benefits can be maintained, it intends to notify providers of NHS-funded care. NHS Improvement will liaise with the Care Quality Commission to ensure that any advice or guidance is also distributed to care homes and hospices.”

Source location

2016-0305-Response-by-Department-of-Health
Page 2 · response
Published 23 August 2016

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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

Follow up the wider safety risks of the crystals with the Health and Safety Executive.

Verbatim wording from the response

“A further consideration is that the use of the sachets appears very widespread, including outside hospital settings. For example, to aid safe disposal of vomit or urine spills in a variety of settings such as nurseries, nightclubs and police cells. Although the manufacturers of these products label them with clear instructions that they are dangerous if put in the mouth, small children, or people who might be under the influence of drugs or alcohol might not read or understand such warnings. NHS Improvement will follow up this angle with the Health and Safety Executive (HSE).”

Source location

2016-0305-Response-by-Department-of-Health
Page 2 · response
Published 23 August 2016

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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

Consider warning staff about the choking risk and the need for risk assessment.

Verbatim wording from the response

“This work will include consideration of a warning to staff of the risk presented and the need for risk assessment as you recommend. However, I am advised that initial considerations by NHS Improvement are that any such warning would have a limited effect, as a high proportion of hospital inpatients have some degree of cognitive or visual impairment, and confused patients might typically pick up urine bottles or other receptacles from other patients. NHS Improvement has further advised that any blanket restriction on their use potentially also risks patient harm through making handling and disposal of bodily fluids more difficult, with an impact on infection control procedures, as well as affecting patient comfort and dignity.”

Source location

2016-0305-Response-by-Department-of-Health
Page 2 · response
Published 23 August 2016

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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

Explore safer alternatives or alternative uses for the solidifying crystals while preserving infection-control and patient-comfort benefits.

Verbatim wording from the response

“Finally, NHS Improvement is exploring whether a safe alternative or alternative ways of using the solidifying crystals that would mean reduced risk without a loss of the benefits they bring to infection control and patient comfort, exists.”

Source location

2016-0305-Response-by-Department-of-Health
Page 2 · response
Published 23 August 2016

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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

Identify an effective method of reducing the choking risk from solidifying crystals.

Verbatim wording from the response

“I am advised that since becoming aware of the findings of the inquest into Mr Dundon’s death, NHS Improvement’s Patient Safety Team has been working to identify an effective method of risk reduction.”

Source location

2016-0305-Response-by-Department-of-Health
Page 2 · response
Published 23 August 2016

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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

Notify providers of NHS-funded care once the most effective choking-hazard controls are identified.

Verbatim wording from the response

“Once NHS Improvement has identified the most effective way of managing the choking hazard while ensuring infection control benefits can be maintained, it intends to notify providers of NHS-funded care. NHS Improvement will liaise with the Care Quality Commission to ensure that any advice or guidance is also distributed to care homes and hospices.”

Source location

2016-0305-Response-by-Department-of-Health
Page 2 · response
Published 23 August 2016

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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

Patient safety leadership and the response to this concern lie with NHS Improvement rather than the Department of Health.

Verbatim wording from the response

“The Department has liaised with a number of agencies to ascertain where responsibility lies for determining the most appropriate response to your concerns.”

Source location

2016-0305-Response-by-Department-of-Health
Page 1 · response
Published 23 August 2016

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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 warning may have limited effect, while a blanket restriction could cause patient harm and undermine infection control, comfort and dignity.

Verbatim wording from the response

“This work will include consideration of a warning to staff of the risk presented and the need for risk assessment as you recommend. However, I am advised that initial considerations by NHS Improvement are that any such warning would have a limited effect, as a high proportion of hospital inpatients have some degree of cognitive or visual impairment, and confused patients might typically pick up urine bottles or other receptacles from other patients. NHS Improvement has further advised that any blanket restriction on their use potentially also risks patient harm through making handling and disposal of bodily fluids more difficult, with an impact on infection control procedures, as well as affecting patient comfort and dignity.”

Source location

2016-0305-Response-by-Department-of-Health
Page 2 · response
Published 23 August 2016

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