Philip Jones

REPORT BY JEMMA CIEROCKI

TO HM CORONER

IN RESPECT OF THE INQUEST OF PHILLIP LESLIE JONES

In the first instance, please extend our condolences to Mr Jones’ loved ones, we understand this
would have been incredibly distressing for them.

Mr Jones was living with a diagnosis of dementia prior to his passing. CQC expects registered
providers to ensure care and support is delivered in a way that manages risk, whilst balancing this
with a person’s independence. After an assessment of his needs, Mr Jones continued to manage his
oral healthcare independently. Fixodent was stored in Mr Jones’ bathroom for him to use and there
were no previous known occasions when Mr Jones had ingested this. As I am sure you are aware,
CQC has specific criminal enforcement powers when avoidable harm has occurred, or when a service
user has been exposed to a significant risk of such harm occurring. Due to the circumstances of Mr
Jones’ passing, we reviewed the incident in line with our specific incident guidance. This was to
establish whether there were failings in care that could have been attributed to a registered
person/provider failure. In summary, we found Mr Jones’ death was not the result of avoidable harm
resulting from a registered person/provider failure.

The provider has investigated the circumstances of Mr Jones’ passing. In summary, the findings
conclude that, while there was no specific risk assessment regarding the management of Fixodent,
Mr Jones had been safely managing his oral health care, and Fixodent use, since his admission to the
service in 2022. As part of the aforementioned investigation, the provider had reviewed lessons
learned. Actions planned by the provider included the organisational sharing of information about
the circumstances of Mr Jones’s passing, to raise awareness. Additionally, identifying residents who
use denture adhesive products, or similar, with a view to reviewing documentation and safety
measures. Although we believe these adhesive gels are not considered medical devices and are thus
not under MHRA’s remit, they may be able to assist with further communications to raise awareness
of the risk with the product manufacturers.

I note you have requested the Chief Executive Officer (CEO) of Fixodent should consider placing a
warning on packaging so it is clear that ingestion of the product is a potential risk. It is important to
consider brands beyond just Fixodent (the CEO of which is listed as the other named respondent in
the Regulation 28 report). There are several brands of denture adhesive gel available which will
potentially carry the same choking risk due to the substance consistency. The patient safety leaflets
of two popular brands of denture adhesive were reviewed and neither contained choking as a
hazard, though they do advise what to do in the event of ingesting or inhaling. It is not within the
CQC’s remit to raise this issue with the CEOs of these companies, so further action may be required
by HM Coroner and/or the Office for Product Safety and Standards.

In terms of action that will be taken by CQC, it is recommended that this incident should be featured
as an issue on CQC’s Learning from safety incidents webpage. This would help raise awareness and
share the learning with providers to help prevent similar incidents in the future. This webpage
should reference:

 Risks relating to denture adhesive gel (as a product generically – there are multiple brands on
the market)



Advise providers to consider denture adhesive gel in the following risk assessments:

 Health and Safety Executive’s COSHH Risk Assessment, in accordance with the Control of

Substances Hazardous to Health Regulations 2002.

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





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Risk assessments carried out relating to the health, safety and welfare of people using
services, in accordance with Regulation 12: Safe care and treatment - Care Quality
Commission. Individualised risk assessment and care planning that should already be
taking place should ensure vulnerable people are identified and protected.

Remind providers of the existing expectation that they should undertake a risk
assessment for oral health in line with NICE guidance.

Advise providers to consider in care planning:

There are also different types of denture adhesives – strips, powder and creams – which
can be used to secure dentures and should be considered on a case-by-case basis.

Existing guidance relating to dementia and oral health, such as is featured on this
webpage dementia UK.

Operations Manager

Richard T. Middleton 
Assistant Coroner 
Dorset Area Coroners 

Procter & Gamble UK 
The Heights, Brooklands, 
Weybridge, Surrey,  
KT13 0XP 
+44 (0) 1932 896000 phone 
+44 (0) 1932 896200 fax 
www.uk.pg.com 

22nd April 2025 

Re: Regulation 28 Prevention of Future Death in respect of Mr. Philip Leslie Jones 

Dear Mr. Middleton, 

We wish to begin by expressing our heartfelt condolences to the family and friends of Mr. Philip Leslie Jones in light of 
the  tragic  circumstances  surrounding  his  passing.  We  recognise  the  gravity  of  the  issues  highlighted  in  the  Coroner’s 
Prevention of Future Deaths report and appreciate the chance to respond.  

Our  commitment  to  safety  is  unwavering.  We  rigorously  assess  the  safety  of  all  our  ingredients  and  finished  products 
before they are introduced, employing well-established risk assessment methods to evaluate potential hazards including 
choking  and  potential  exposures.  These  evaluations  are  integral  to  our  product  development  process   starting  from  the 
early  design  stages  and  continuing  after  the  products  are  made  available  on  the  market.  Ensuring  the  safety  of  our 
products,  packaging,  and  operations  for  our  employees,  consumers  and  the  environment  is  a  fundamental  aspect  of 
conducting responsible business and is crucial for building and maintaining public trust.  

It is important to clarify that Fixodent products fully comply with EU and UK medical device regulations. We provide 
clear  usage  instructions  on  the  product,  its  packaging  and  the  accompanying  leaflet.  They  are  safe  and  do  not  pose  a 
choking risk when used as intended and directed, as supported by Mr. Jones's previous experience with denture adhesive 
cream.  

Our  commitment  to  consumer  safety  is  evident  in our  comprehensive  post -market  surveillance  system  which  monitors 
any adverse events related to our products. This proactive approach aims to prevent future incidents and enhance overall 
consumer safety. The data from our surveillance system confirms that the product is safe with clear usage instructions.  

We  acknowledge  and  respect  the  Coroners’  perspective  that  this  product  should  be  considered  in  risk  assessments  for 
individuals living in care home settings. We also believe that  all products, not just oral care items, should be included in 
initial and regular risk assessments for those living with dementia in care home settings. On the day of his death , it was 
reported that denture adhesive cream was found in Mr. Jones’s ears and nose indicating that the product was not used as 
intended which is crucial for understanding this incident. 

Given these considerations, we are not proposing changes to our product or its packaging at this time. We will continue 
to monitor any adverse events related to the product to ensure its ongoing safety. 

Thank  you  for  allowing  us  to  address  these  concerns.  We  remain  committed  to  ensuring  the  safety  and  well -being  of 
those who use our products and once again extend our deepest sympathies to Mr. Jones' family and friends.  

Yours sincerely, on behalf of Fixodent 

Senior Communications Director 

Procter & Gamble UK, a partnership between Procter & Gamble (L&CP) Limited, registered in England and Wales under Company No. 3288185, and Procter & Gamble (Health & 
Beauty Care) Limited, registered in England and Wales under Company No. 436549.  The Heights, Brooklands, Weybridge, Surrey, KT13 0XP.