PFD report

Jane Ann FENWICK · Prevention of Future Deaths report

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Issued 19 Feb 2026•Northamptonshire

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.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
3

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 refer people at risk of choking to Speech and Language Therapy for support and intervention
    Part of recurring concern: Failure to provide timely speech and language therapy for swallowing risksPart of recurring concern: Unsafe implementation of choking-risk prevention measures
  2. Delays in access to Speech and Language Therapy support
    Part of recurring concern: Failure to provide timely speech and language therapy for swallowing risks
  3. Failure to supervise people while eating in accordance with care plans
    Part of recurring concern: Failure to provide required mealtime supervision
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.2

  1. Action

    Publish guidance outlining recommended actions to reduce community health service waiting times.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
  2. Action

    Fund eligible adult social care staff to undertake nutrition, hydration, choking prevention and response training through the Learning and Development Support Scheme.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.

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

  1. Position

    Local services determine SALT referral criteria and make referral decisions according to individual patient need.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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

Failure to refer people at risk of choking to Speech and Language Therapy for support and intervention

Wider context from the report

“Mrs Fenwick:- a) had no teeth b) did not wear her dentures c) had a tendency to rush her food d) had a tendency to put too much in her mouth e) had poor posture and generally did not sit at a table to eat f) did not sit still g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating) h) had a preference for softer food i) had a care plan which identified a risk of choking Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking. The care home also said in evidence that the average wait for SALT support is 13 weeks. I have concerns regarding the threshold for intervention/support and the current waiting lists. ”

Is this part of a recurring concern?

Yes — Failure to provide timely speech and language therapy for swallowing risks; 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

Delays in access to Speech and Language Therapy support

Wider context from the report

“Mrs Fenwick:- a) had no teeth b) did not wear her dentures c) had a tendency to rush her food d) had a tendency to put too much in her mouth e) had poor posture and generally did not sit at a table to eat f) did not sit still g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating) h) had a preference for softer food i) had a care plan which identified a risk of choking Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking. The care home also said in evidence that the average wait for SALT support is 13 weeks. I have concerns regarding the threshold for intervention/support and the current waiting lists. ”

Is this part of a recurring concern?

Yes — Failure to provide timely speech and language therapy for swallowing risks.

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 supervise people while eating in accordance with care plans

Wider context from the report

“Mrs Fenwick:- a) had no teeth b) did not wear her dentures c) had a tendency to rush her food d) had a tendency to put too much in her mouth e) had poor posture and generally did not sit at a table to eat f) did not sit still g) was generally not supervised whilst eating (despite the care plan recommending she be observed while eating) h) had a preference for softer food i) had a care plan which identified a risk of choking Despite the above, Mrs Fenwick had not been referred to Speech and Language Therapy (SALT). The care home’s evidence was that even if Mrs Fenwick had been referred to SALT, she would not have met their threshold for support and intervention on the basis that there had been no previous episodes of choking. The care home also said in evidence that the average wait for SALT support is 13 weeks. I have concerns regarding the threshold for intervention/support and the current waiting lists. ”

Is this part of a recurring concern?

Yes — Failure to provide required mealtime supervision.

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

Publish guidance outlining recommended actions to reduce community health service waiting times.

Verbatim wording from the response

“The recently published NHS England » Community health services waiting times: actions to meet Medium term planning framework targets guidance outlines recommended actions to support achievement of the Medium-Term Planning”

Source location

2026-0104 - Response from NHS England
Page 2 · response
Published 24 February 2026

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

Fund eligible adult social care staff to undertake nutrition, hydration, choking prevention and response training through the Learning and Development Support Scheme.

Verbatim wording from the response

“Any form of neglect is unacceptable, and my department recognises the importance of safe, person-centred care, particularly in relation to eating and drinking. This is why the Adult Social Care Learning and Development Support Scheme (LDSS), was launched in September 2024, and provides funding for eligible care staff to undertake courses and qualifications, including the Level 2 Certificate in Understanding Nutrition and Health and relevant content in the Level 2 Adult Social Care Certificate (L2ASCC).”

Source location

2026-0104 - Response from Department of Health and Social Care
Page 1 · response
Published 24 February 2026

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

Local services determine SALT referral criteria and make referral decisions according to individual patient need.

Verbatim wording from the response

“The referral criteria for SALT is agreed locally, aligned to commissioning and service models but referral decisions should be based on an individual’s need. Not having a previous choking episode should not prevent a referral if the wider clinical history and risk of choking are recognised and included in the referral.”

Source location

2026-0104 - Response from NHS England
Page 1 · response
Published 24 February 2026

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

Integrated Care Boards are responsible for increasing community SALT capacity and managing waiting times under national planning requirements.

Verbatim wording from the response

“The Medium-Term Planning Framework states that in 2026/27, Integrated Care Boards are required to:”

Source location

2026-0104 - Response from NHS England
Page 2 · response
Published 24 February 2026

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

NHS England is responsible for reporting separately on current Speech and Language Therapy waiting lists.

Verbatim wording from the response

“In preparing this response to your first concern, departmental officials have made enquiries with Care Quality Commission (CQC) and North Northamptonshire Council (NNC) and Chair of the Northamptonshire Safeguarding Adults Board (NSAB). Officials did this to gain a greater insight into any specific reasons for Mrs Fenwick not being referred to SALT and what, if any, follow up actions may have resulted from this case. However, with regards to the second concern, then NHS England, who also received a copy of this report, will be reporting separately on current waiting lists for SALT.”

Source location

2026-0104 - Response from Department of Health and Social Care
Page 1 · response
Published 24 February 2026

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.1

  1. 1

    Discuss all Regulation 28 reports through the national working group and share key learning across NHS national and regional services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.

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

  1. 1

    North Northamptonshire Council considers the incident isolated, with no similar risks or failings warranting a Safeguarding Adults Review referral.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Discuss all Regulation 28 reports through the national working group and share key learning across NHS national and regional services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Mrs Fenwick, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

2026-0104 - Response from NHS England
Page 3 · response
Published 24 February 2026

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

North Northamptonshire Council considers the incident isolated, with no similar risks or failings warranting a Safeguarding Adults Review referral.

Verbatim wording from the response

“Separately NNC have indicated that in their view, although this was a tragic incident, it is being viewed as an isolated incident, as it has been determined that there are no similar risks to other people in the service or identified failings to warrant a Safeguarding Adults Review Referral under section 44 of the Care Act. However, the NNC will be engaging, alongside the NSAB, with the coroner and if any additional information becomes available, then NNC will consider this and any associated learning.”

Source location

2026-0104 - Response from Department of Health and Social Care
Page 2 · response
Published 24 February 2026

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