Care homes should monitor Dysphagia risk

“A care home company has been fined over £1.8 million after a resident choked on a piece of food while consuming her evening meal alone in her room.

Elizabeth Campbell (known as Peggy) was a 96-year-old resident of Cradlehall Care Home in Inverness. She was on a specialist diet of soft, moist and bite-sized food and her care plan stated that she should be closely supervised when eating and drinking.

The Court heard that on 11 June 2022, the unit where Peggy resided was staffed by two agency carers who were responsible for twelve residents. At about 5.45pm, Peggy was served a meal of macaroni and chips while sitting up in bed.

One of the carers left to get a drink to accompany her meal but was then forced to deal with urgent issues with two other residents which required her to call for assistance from another unit. As a result of this disruption the resident was left on her own for up to 20 minutes by the time the carer returned to her room with the drink.

The carer raised the alarm, and other staff came to assist. A paramedic arrived shortly afterwards and the woman was pronounced dead.

An investigation by the Health and Safety Executive (HSE) concluded that Peggy’s death was caused by the fact the company had failed to ensure that all those working in the home had access to and were familiar with the care plans of its residents and that crucially Peggy had been left unsupervised while eating.  Following the investigation, HSE took action against the company, with improvements later being made to ensure there was a ‘skills mix’ during shifts – ensuring any agency staff were always assisted by regular employees, who were more aware of the needs of the home’s residents.

HC-One Limited, who run the care home, pleaded guilty to failings under the Health and Safety at Work etc Act 1974. The company was fined £1.8 million at Inverness Sheriff Court on 20 October 2025”

The above report from the HSE Press Release. The following guidance is from the BMJ:

Dysphagia (difficulty with the act of swallowing solids or liquids) affects an estimated 22–68% of nursing home residents in the UK, depending on the study.

It may be subjective or objective and can refer to the sensation of not being able to swallow, food 'sticking' or not passing, choking episodes, or aspiration of food and/or liquids. It should be distinguished from odynophagia (pain on swallowing) and globus sensation (sensation of a lump in the throat between meals).

 Dysphagia can be caused by functional or structural abnormalities of the oral cavity, pharynx, oesophagus, or gastric cardia. Residents with dementia, stroke, Parkinson's disease, and motor neurone disease are at particular risk.

One in 17 people will develop dysphagia in their lifetime. The condition is reported to occur in 13% of the general population aged 65 years and older.However, rates of 50% or more have been reported in older individuals in residential care. Dysphagia affects 40% to 70% of people with stroke.

Dysphagia is reported at initial presentation in up to 28% of of patients with head and neck cancer, and in up to 50% of patients with pharyngeal cancers (3 highest causal factors HPV, Smoking, Alcohol) It is also an acute and chronic adverse effect of treatment for head and neck cancer.

Dysphagia may be treated by various specialties or ideally by a multi-specialty team. The core of such a team includes the patient’s primary care physician, otolaryngologists, speech and swallowing therapists, gastroenterologists, and radiologists. In addition, neurologists, dieticians, oncologists, general surgeons, and thoracic surgeons are often involved in the patient’s care.

Swallowing, and therefore difficulty swallowing, can be anatomically and physiologically divided easily into three distinct parts: the oral phase, the pharyngeal phase, and the oesophageal phase.

• The oral phase (sometimes referred to as the preparatory phase) is the voluntary phase that occurs in the oral cavity. Mastication with salivary lubrication and tongue movement prepares the bolus to be thrust posteriorly into the pharynx.

• The pharyngeal phase involuntarily transfers the bolus of food and/or liquid from the mouth to the oesophagus. Its coordinated contractions not only are necessary to propel the bolus but are crucial in protecting the larynx and upper airway from aspiration of material into the airway and lung.

• The oesophageal phase is the involuntary phase that utilises peristalsis to propagate the food/liquid bolus through the oesophagus into the stomach. The oesophagus is bound by upper and lower sphincters (the upper formed by the cricopharyngeus muscle), which prevent retrograde flow of stomach contents into the oesophagus.

By way of guidance to care home practitioners I found the following advice online:

The IDDSI Framework — adopted as the UK care sector standard — defines eight levels of food and drink texture.

0 - thin drinks

1 - slightly thick drinks

2 - mildly thick drinks

3 - liquidised food and moderately thick drinks

4 - Pureed food and very thick drinks

5 - Minced and moist food

6 - Soft bite sized food

7 - Regular food

What HSE expects a care home to have in place:

• A documented system for identifying residents with swallowing difficulties. Each resident with dysphagia should have a documented IDDSI level in their care plan, and all food preparation should be tested and verified against that level before serving.

• A process for communicating resident  requirements to kitchen and care staff

• Training records showing all food-preparation staff have received training

• A method for verifying texture before serving (flow test for drinks, fork/spoon pressure tests for foods)

• An incident log for any deviation or near-miss

• Named accountability for risk management system — usually the registered manager or deputy