Leslie Horsfield · Prevention of Future Deaths report

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Issued 18 Jun 2021•Manchester North

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
2

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 prompts in admissions assessment tools to ask about previous choking episodes
    Part of recurring concern: Failure to incorporate relevant clinical history and diagnoses into care decisions

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Northern Care Alliance NHS Foundation Trust

    Share lessons from the inquest with Trust staff.

  2. Northern Care Alliance NHS Foundation Trust

    Update the nursing admission proforma to ask whether patients have previously experienced choking episodes during the EPR rollout.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Northern Care Alliance NHS Foundation Trust

    Existing swallowing questions are considered adequate to manage choking risk despite lacking a specific question about previous choking episodes.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 prompts in admissions assessment tools to ask about previous choking episodes

Wider context from the report

“The absence of any prompt in the admissions assessment tool which reminds assessors to ask patients about previous choking episodes creates a risk that relevant information is missed from the assessment and places the onus on the patient to volunteer information which they may not appreciate is relevant to the assessment ”

Is this part of a recurring concern?

Yes — Failure to incorporate relevant clinical history and diagnoses into care decisions.

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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

Share lessons from the inquest with Trust staff.

Verbatim wording from the response

“I acknowledge that there are lessons emanating from this inquest, these have been shared with our staff. It is my experience that our employees are always receptive to learning, especially where it promotes good practice and enhances patient safety.”

Source location

2021-0215-Response-from-Northern-Care-Alliance_Published
Page 2 · response
Published 28 June 2021

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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 nursing admission proforma to ask whether patients have previously experienced choking episodes during the EPR rollout.

Verbatim wording from the response

“Having considered the matter further, I would like to provide you with assurance that as part of our Electronic Patient Record (EPR) Programme roll-out across the North East Sector, the nursing admission proforma will be updated to ask whether the patient has previously experienced any choking episodes. The timeframe for implementation of EPR across Pennine is Spring 2023.”

Source location

2021-0215-Response-from-Northern-Care-Alliance_Published
Page 2 · response
Published 28 June 2021

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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

Existing swallowing questions are considered adequate to manage choking risk despite lacking a specific question about previous choking episodes.

Verbatim wording from the response

“Having discussed this with senior nursing colleagues within the Trust, it is however maintained that the nursing admission proforma provides the assessor with the ability to adequately explore a patient’s swallowing capability. Whilst the nursing assessment does not ask a specific question in relation to previous episodes of choking, the assessment does clearly question patients in relation to any problems with eating and drinking, the need for modified dietary consistency, or anything else to prompt a referral to Speech and Language Therapy.”

Source location

2021-0215-Response-from-Northern-Care-Alliance_Published
Page 1 · response
Published 28 June 2021

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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