Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
Choking can result in serious or fatal injuries and is avoidable in cases where there is a known risk.
Dysphagia is the medical term for swallowing difficulties. If a person with dysphagia is at risk of choking, they will usually see a speech and language therapist (SALT). You should have detailed plans in place for the affected person. The plans need to tell your care staff how to prepare their food and drink.
Prosecution by CQC
In 2017, CQC prosecuted a care home provider for failing to manage risks to people’s safely. One of those risks involved a choking incident.
The provider failed to:
- make sure that staff understood how to safely support a 77-year-old man to eat and drink. This was because they did not pass on advice from his SALT
- maintain accurate care records
The man had seen a SALT for a swallowing assessment in March 2015. The SALT recommended normal fluids and a pre-mashed diet. The SALT also recommended that he should be upright and have his head supported to eat and drink. The provider did not review the man’s diet. They did not update the man’s care records until six weeks after the assessment. Even then the provider did not include information about how care staff should support the man.
In June 2015 the man choked on his porridge while he was receiving his breakfast in bed. He was admitted to hospital. The SALT assessment was not sent to the hospital with him. He was re-admitted to hospital that evening after choking again on thick porridge. The hospital diagnosed aspiration pneumonia. This is caused by food or fluids getting into the lungs.
We assessed the provider’s care records. This showed that staff were unclear about:
- the consistency of the food and drink they should have been giving to the man
- how they should be supporting him to eat and drink safely
This lack of clarity put the man at significant risk, which led to his serious illness.
The provider admitted guilt to an offence of failing to provide safe care and treatment. This failure resulted in a significant risk of exposure to avoidable harm. The choking incident was one of 14 offences considered.
The court ordered the provider to pay:
- a £82,429.72 fine
The service was urgently closed
In 2015, we inspected this service. We found numerous serious failings and took urgent action to deregister this provider. The magistrate granted a closure order in June 2015.
What can you do to avoid this happening?
Unfortunately, this sort of incident is not uncommon. People should be appropriately assessed by a skilled and competent healthcare professional. You should tailor each person's care plan to their individual needs.
Public Health England produce a helpful guide around the management of Dysphagia.
We also provide useful information about medicines for providers.
New developments
The International Dysphagia Diet Standardisation Initiative has published international standardised descriptors. These address texture-modified foods and thickened liquids for people with dysphagia. You should have been using these since April 2018. The British Dietetic Association and the Royal College of Speech and Language Therapists have adopted these guidelines. They replace previous descriptors. You should put these changes in place safely to protect people from choking risks.
Learning from safety incidents
Each of these pages describes a critical issue: what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
See also
Resources to support safer modification of food and drink