Prabhaker Nath Kapoor · Prevention of Future Deaths report

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Issued 6 Aug 2019•Birmingham and Solihull

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
2

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

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 raised2

  1. Failure to update the MOODLE training package
  2. Failure to complete the review of safer swallowing training

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. University Hospitals Birmingham NHS Foundation Trust

    Submit the updated swallowing-related standard operating procedures for ratification by the Operational Quality Assurance Group.

  2. University Hospitals Birmingham NHS Foundation Trust

    Continue reviewing the evidence on water restriction for patients receiving thickened fluids and determine whether current procedures remain reasonable.

  3. University Hospitals Birmingham NHS Foundation Trust

    Develop and disseminate a practice update on managing hospital patients with swallowing difficulties to all staff.

  4. University Hospitals Birmingham NHS Foundation Trust

    Establish a task and finish group to review safer swallowing practices and align education, policy and procedure documents across the Trust.

  5. University Hospitals Birmingham NHS Foundation Trust

    Disseminate the ratified swallowing-related standard operating procedures to all staff through communications channels and the intranet.

  6. University Hospitals Birmingham NHS Foundation Trust

    Review and update standard operating procedures for managing dysphagia and nil-by-mouth patients.

  7. University Hospitals Birmingham NHS Foundation Trust

    Complete development and release the updated Moodle dysphagia and nil-by-mouth training package for new and existing staff.

  8. University Hospitals Birmingham NHS Foundation Trust

    Provide monthly preventing-harm study days with specialist-led training for new and existing staff, including the updated swallowing procedures.

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

  1. University Hospitals Birmingham NHS Foundation Trust

    Pending further literature review, adherence to the current recommendations on water restriction for patients receiving thickened fluids must be maintained.

    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

Failure to update the MOODLE training package

Wider context from the report

“I heard evidence that a review of safer swallowing training was to be provided to staff on team training days, and that changes would be made to the MOODLE training package by the Speech and Language Manager. The RCA report carried out by Matron ████████ indicated that this should have been completed by 15th May 2019, but in oral evidence it was revealed that this had not been done, and an estimated timeframe for completion could not be provided to me. Whilst it was suggested that confirmation could be submitted to HM Coroner upon successful completion of this review, HM Coroner would be functus officio. I therefore suggest that the Trust consider carrying out this review of safer swallowing and update the MOODLE training package as a matter of urgency. ”

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 complete the review of safer swallowing training

Wider context from the report

“I heard evidence that a review of safer swallowing training was to be provided to staff on team training days, and that changes would be made to the MOODLE training package by the Speech and Language Manager. The RCA report carried out by Matron ████████ indicated that this should have been completed by 15th May 2019, but in oral evidence it was revealed that this had not been done, and an estimated timeframe for completion could not be provided to me. Whilst it was suggested that confirmation could be submitted to HM Coroner upon successful completion of this review, HM Coroner would be functus officio. I therefore suggest that the Trust consider carrying out this review of safer swallowing and update the MOODLE training package as a matter of urgency. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Submit the updated swallowing-related standard operating procedures for ratification by the Operational Quality Assurance Group.

Verbatim wording from the response

“Following review the documents have been updated and we are satisfied that they provide all our staff with clear guidance, rationale and clinical expectations when managing and caring for patients who have dysphagia and/or are placed nil by mouth. There has been consultation with a consultant oncologist, consultant geriatrician, consultant ear nose and throat surgeon, palliative care consultant and lead for nursing education. The standard operating procedures have been reviewed by our task and finish group referred to above and will be reviewed and ratified by our Operational Quality Assurance Group on 1 October 2019. Following ratification the documents will be disseminated to all staff via our communications team and will also appear on our intranet.”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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 reviewing the evidence on water restriction for patients receiving thickened fluids and determine whether current procedures remain reasonable.

Verbatim wording from the response

“All that having been said we recognise that the evidence base for restriction of water in those on a thickened fluid regime is extremely weak. There is no NICE recommendation in either direction; NICE simply references a Cochrane systematic review of the limited literature. This systematic review identifies no evidence of excess risk associated with access to water in this group of patients. We will continue to review this literature and determine whether our current procedures remain reasonable. In the meantime we are though clear that trust wide adherence to current recommendations must be maintained.”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Develop and disseminate a practice update on managing hospital patients with swallowing difficulties to all staff.

Verbatim wording from the response

“Practice update”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Establish a task and finish group to review safer swallowing practices and align education, policy and procedure documents across the Trust.

Verbatim wording from the response

“Following this incident a task and finish group was set up, chaired by our Deputy Chief Nurse, to review safer swallowing practices across the Trust and to review the ongoing work to align our education provision, policy and procedure documents.”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Disseminate the ratified swallowing-related standard operating procedures to all staff through communications channels and the intranet.

Verbatim wording from the response

“Following review the documents have been updated and we are satisfied that they provide all our staff with clear guidance, rationale and clinical expectations when managing and caring for patients who have dysphagia and/or are placed nil by mouth. There has been consultation with a consultant oncologist, consultant geriatrician, consultant ear nose and throat surgeon, palliative care consultant and lead for nursing education. The standard operating procedures have been reviewed by our task and finish group referred to above and will be reviewed and ratified by our Operational Quality Assurance Group on 1 October 2019. Following ratification the documents will be disseminated to all staff via our communications team and will also appear on our intranet.”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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 standard operating procedures for managing dysphagia and nil-by-mouth patients.

Verbatim wording from the response

“Review of standard operating procedures”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Complete development and release the updated Moodle dysphagia and nil-by-mouth training package for new and existing staff.

Verbatim wording from the response

“University Hospitals Birmingham NHS Foundation Trust (the Trust) has carefully considered the concerns raised within your report to prevent future deaths regarding a review of safer swallowing and update of our Moodle training package.”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 1 · response
Published 18 October 2019

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 monthly preventing-harm study days with specialist-led training for new and existing staff, including the updated swallowing procedures.

Verbatim wording from the response

“Rolling education programme – ‘preventing harm study days’”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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

Pending further literature review, adherence to the current recommendations on water restriction for patients receiving thickened fluids must be maintained.

Verbatim wording from the response

“All that having been said we recognise that the evidence base for restriction of water in those on a thickened fluid regime is extremely weak. There is no NICE recommendation in either direction; NICE simply references a Cochrane systematic review of the limited literature. This systematic review identifies no evidence of excess risk associated with access to water in this group of patients. We will continue to review this literature and determine whether our current procedures remain reasonable. In the meantime we are though clear that trust wide adherence to current recommendations must be maintained.”

Source location

2019-0278-Response-by-Birmingham-Hospitals-NHS-Trust
Page 2 · response
Published 18 October 2019

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