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Prevention of Service Users Choking

Following a recent CQC inspection Report a care home was rated ‘inadequate’ and placed in special measures. One of the reasons for the poor rating was because Inspectors found that risks related to people swallowing and choking were not being managed.

Given the risk of choking to service users how can services ensure the risk be best managed?


When a service user is admitted to a care home or seeks support of a domiciliary care service an assessment of the overall physical, psychological and social assessment of the service user’s ability to perform certain tasks independently, with some degree of assistance or supervision should be carried out. On admission, an oral assessment should be carried out to determine whether the service user has his or her own teeth, missing teeth, has no teeth or the service user has partial dentures or full dentures.

Additionally, staff should assess the condition of the service users’ teeth and oral cavity, including the gums and tongue. The alert and oriented service user may be able to answer many of the questions regarding his or her teeth, and family members often provide additional pertinent information.

Included in the oral assessment is the service user’s ability to eat. Staff should interview the service users and their family to gather information regarding usual eating capabilities. If the service user has a diagnosis or history of swallowing difficulties, dementia or other cognitive deficits, such information are “red flags” that must be communicated to the GP to ensure that the diet to be provided is suitable, and meets the needs of the service user.  A planned menu should form part of the service users care plan.

In addition, an initial risk assessment followed by ongoing risk assessments should be carried out

What is choking?

Choking is blockage of the upper airway by food or other objects, which prevents a person from breathing effectively. Choking can cause a simple coughing fit, but complete blockage of the airway may lead to death.

When food blocks the service user’s airway, it cuts off the supply of oxygen to the lungs. The brain is very sensitive to lack of oxygen and begins to die within four to six minutes. If First Aid is not started during this time, hypoxia will lead to brain damage and ultimately death.

Many of us experience some degree of choking in our lives. However, choking in care services must be viewed differently because the social care service has a duty of care to service users.

Identifying the risks to Service users

Human error accounts for the vast majority of choking deaths in care services, as staff may have given the wrong diet (regular diet instead of required altered consistency). Staff must exercise due diligence in meal preparation and service. They must also be aware of “red flags” that should put them on notice that a service user may be at a high risk for choking, including but not limited to:

  1. Cognitive deficits (forgetful or confusion, especially where service user has Alzheimer’s Dementia);

  2. Difficulty swallowing;

  3. Inability to chew;

  4. Poor dentition;

  5. Lack of teeth(edentulous);

  6. Ill-fitting dentures;

  7. Excessive coughing during meals; and

  8. An episode of acute illness, such as pneumonia or urinary tract infection.

Reducing the risk by following policies and procedures

Social care services should ensure that they have policies and procedures in place to reduce the risk of choking. Bettal Quality Consultancy have policies on the prevention of Choking and Oral Assessment that form part of the Bettal Quality Management System.

Staff should be mindful of:

  1. An identified swallowing disorder in a service user;

  2. A healthcare practitioner’s order for an altered textured diet;

  3. Behaviour plan that addresses eating behaviours, including but not limited to rapid eating, stuffing food, pica or food stealing;

  4. Altered mental status in a service user;

  5. Progression of Dementia; and

  6. Possible change of condition due to an acute illness or hospitalisation.

Staff should follow the “five rights” for service users meal service:

  1. Right service user;

  2. Right diet;

  3. Right consistency;

  4. Right eating location (dining room, feeding room, or bedroom); and

  5. Right level of assistance and/or supervision.


The CQC Inspectors Report that found risks related to people swallowing and choking were not being managed, shows once again that social care services must have policies and procedures based on best practice that address the prevention of choking and oral hygiene.

The red flags and the five rights I have described in this blog along with assessment, an understanding of choking, the correct preparation of food and supervision of service users at meal times, may go some way to assuring inspectors there is evidence to support swallowing and choking is being managed.

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy

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