Madeline Reding

Mr Graeme Irvine – His Majesty’s Senior Coroner for 
East London 
The Coroner's Office 
East London Coroner's Court 
Queens Road 
Walthamstow 
E17 8QP 

            19 August 2025 

Dear Sir, 

The Inquest Touching the Death of Mrs Madeline Reding (DoB: 21/11/1944)  
Regulation 28 Report – Action to Prevent Future Deaths – Aspray House Nursing 
Home dated 21 July 2025 (the “Report”) 

I refer to the above and write to provide Aspray House’s response to the Regulation 28 
Report to Prevent Future Deaths, received on 21 July 2025. 

The Report confirms that the due date for our response is 56 days from the Report, so 15 
September 2025. 

This response is made under paragraph 7(2) of Schedule 5 of the Coroners and Justice 
Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.  
We understand the response must contain detail of action taken or proposed to be taken, 
setting out a timetable for action.  Otherwise, we must explain why no action is proposed. 

The Coroner’s concerns are as follows: - 

1.  The inquest found that staff responses to the developing emergency were delayed 
and disorganised.  Despite four registered nurses being present at the scene, no 
effective leadership of the emergency response was witnessed. 

2.  An emergency alarm was not sounded promptly. 
3.  A  999  call  was  not  made  immediately  on  discovering  Mrs  Reding  was 

unresponsive. 

4.  Despite  specific  instructions  to  commence  CPR  being  given  on  three  separate 
occasions by a London Ambulance Service call dispatch handler, resuscitation was 
not commenced by a registered nurse as she did not appreciate that a “Do not 
attempt cardio-pulmonary resuscitation order” would not apply to the patient in the 
event that the cardiac arrest was due to a reversible cause, such as choking. 

5.  First aid that was administered was ineffective. 

a.  Back slaps were weak. 
b.  Abdominal thrusts were not attempted. 
c.  Chest  compressions  were  only  commenced  over  ten  minutes  after  Mrs 

reding was found to have stopped breathing. 

Aspray House Ltd trading as Aspray House. 
Trading Address: 481 Lea Bridge Road, Leyton, London, E10 7EB 
Telephone: 020 8558 9579 | Email: info@asprayhouse.co.uk | Web: www.asprayhouse.co.uk 
Registered Address: 31-33 Commercial Road, Poole, Dorset BH14 0HU (Company Registration No. 04648705) 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Post incident actions 

We have addressed the First Concern in the Report as below: - 

The two Duty Lead nurses involved, along with all permanent and agency staff who work 
at Aspray House have been given extensive training (which we will address in further detail 
below), whilst the Home Manager and Deputy Operations Manager employed at the time 
who were involved in the incident (who were also registered nurses at that time) have been 
replaced with new management. 

We have addressed the Second, Third, Fourth and Fifth Concerns in the Report as below:-  

Policies were already in place prior to the incident in respect of Swallowing Difficulties and 
Basic  Life  support,  Resuscitation  and  DNARCPR  which  were  not  followed  by  the  staff.  
These policies included instructions to dial 999, to give up to five back slaps followed by 
up  to  five  abdominal  thrusts,  commence  CPR  if  unresponsive,  and  use  de-choking 
equipment (if trained).  Additionally, all nursing and care staff were required to undertake 
annual First Aid Practical training and annual training on how and when to the use of Life-
Vac de-choker equipment in choking situations. 

Immediately following the incident, an urgent flash Lessons Learnt training session was 
held with all nursing staff (including the management nurses present at the incident) on 23 
May 2025 to reinforce the existing Swallowing Difficulties policy and Basic Life support, 
Resuscitation and DNARCPR policies and the procedures to be followed in the event of a 
choking incident.  Both policies were subsequently reviewed on 31 July 2024 and noted to 
be compliant with Resuscitation Council, Royal College of Nursing and CQC guidance.   

Extensive anti-choking and First Aid training followed with all staff, both permanent and 
agency and including care staff and non-care staff, where all staff received group training 
along with individual competency testing where this incident was discussed and the policy 
and procedures were reinforced to prevent a recurrence.  Further refresher training was 
held three months later to reinforce the policies and lessons learnt. 

Senior  management  designed  a  simple  to  follow  colour  coded  Choking  Flow  Chart  in 
October  2024  which  is  compliant  with  current  guidance  and  which  has  been  placed  on 
display in all nursing stations throughout Aspray House reinforcing the policy, procedure 
and expectations of how all staff should deal with choking situations – including highlighting 
that CPR must be attempted if suitable even on residents with a DNAR in place.  This has 
been supplemented with a pictorial Choking First Aid poster for universal understanding 
which has been displayed in all dining areas. 

In October 2024, Aspray House also purchased an Act Fast Anti Choking Trainer Vest for 
use in practical training to ensure that all staff are proficient in back slaps and abdominal 
thrusts.    Students  wear  the  Choking  Vest  to  learn  the  correct  manoeuvres which when 
performed correctly shoots a foam plug into the air.  It also includes a foam back slap pad 
for  practicing  effective  back  slaps.    Thus,  making  instruction  realistic  and  leaving 
participants  confident  in  their  actions  and  their  response  to  a  genuine  choking  incident 
should one occur.  

Aspray House Ltd trading as Aspray House. 
Trading Address: 481 Lea Bridge Road, Leyton, London, E10 7EB 
Telephone: 020 8558 9579 | Email: info@asprayhouse.co.uk | Web: www.asprayhouse.co.uk 
Registered Address: 31-33 Commercial Road, Poole, Dorset BH14 0HU (Company Registration No. 04648705) 

 
 
 
 
 
 
 
 
 
 
 
 Following a subsequent meeting with the Local Authority and taking on board its concerns 
that  all  post-incident  training  competences  and  assessments  were  conducted  in-house, 
Aspray  House  also  engaged  a  private  training  provider  –  Michael Hughes Training  -  to 
assess its staffs’ competency in choking training.  This training was undertaken on a two-
day rotation on 21 and 31 March 2025 with individual assessments conducted with all 73 
staff members working at the home (both permanent and agency staff).  We confirm that 
all staff members successfully passed the course. 

Aspray House also purchased its own defibrillator on 22 May 2025 which is located within 
the  Manager’s  office  on  the  first  floor  of  the  Home.    Posters  displaying  its  location  are 
displayed beside the Choking First Aid poster in all dining areas with all staff having been 
given guidance on its use. 

Aspray House noted the Coroner’s concerns at the Inquest that even where a choking risk 
assessment had been carried out and a resident not identified as having a choking risk, 
that a diagnosis of dementia could cause a risk of choking.  Immediately after the inquest 
concluded, Aspray House implemented warnings being added to the Care Plans for every 
resident with a dementia diagnosis the following day.  This new warning is displayed on 
the first page of a patient’s Care Notes on the hand-held PCS devices used by all staff and 
highlights a risk of choking (regardless of the score achieved against a standard choking 
risk assessment) due to dementia and that choking is a potentially reversible situation and 
that CPR should be commenced if suitable.   

All  staff  are  now  given  choking  training  on  a  6-monthly  basis  regardless  of  their  role 
(including  agency  staff)  –  whether  they  be  nurses,  carers,  cooks,  housekeepers, 
maintenance staff etc. 

LifeVac training and Basic First Aid training is also mandatory for all staff (employees and 
agency)  and  is  to  be  completed  before  a  new  staff  member  commences  work  with 
residents and are both refreshed annually.  All pre-existing staff must refresh their LifeVac 
and  Basic  First  Aid  training  on  an  annual  basis  and  a  training  matrix  is  held  to  ensure 
compliance. 
In summary, we provide a list of actions taken with the relevant dates for each and evidence 
of such attached under Exhibit “AM1” as follows: -  

Action Taken 

Urgent  Flash  Lessons  Learnt  training  with  all 
nursing staff.  Disseminated to all staff via flash 
daily meetings. 
Face  to  Face Anti-choking  training  conducted 
with  all  staff  (nursing,  care,  housekeeping, 
maintenance, activities staff). 
One to one choking competency assessments 
undertaken  on  all  care  staff  (including  agency 
staff) who assist residents at mealtimes. 
Swallowing Difficulties policy reviewed. 

Date of Action 

23/05/2024 

AM1 

Exhibit 
Page No. 
1 

24/06/2024 
03/07/2024 

02/07/2024 
13/09/2024 

– 

– 

2 

3 - 5 

31/07/2024 

6 - 10 

Aspray House Ltd trading as Aspray House. 
Trading Address: 481 Lea Bridge Road, Leyton, London, E10 7EB 
Telephone: 020 8558 9579 | Email: info@asprayhouse.co.uk | Web: www.asprayhouse.co.uk 
Registered Address: 31-33 Commercial Road, Poole, Dorset BH14 0HU (Company Registration No. 04648705) 

 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 Basic Life support, Resuscitation and 
DNARCPR policy reviewed. 

31/07/2024 

11 - 18  

Choking Act Fast refresher training held for all 
nursing and care staff and follow up training on 
Lessons Learnt. 
Choking Flow Chart designed and placed in all 
nursing stations. 

14/10/2024 
15/10/2024 

October 2024 

Pictorial  Choking  First  aid  posters  purchased 
and placed in all dining areas. 

October 2024 

- 

19 - 20 

21 

22 

Act  Fast Anti  Choking  Vest  purchased  for  use 
practical  training  in  back  slaps  and  abdominal 
thrusts. 
External  Choking  (Adult)  Training  undertaken 
for all staff with Michael Hughes Training. 

Defibrillator  purchased  for  Aspray  House  and 
located  in  the  Manager’s  office  with  signage 
through all dining areas. 

Care  Notes  for  all  residents  with  a  dementia 
diagnosis  updated  to  add  a  risk  of  choking  or 
aspiration (regardless of their standard choking 
risk  assessment  score),  and  that  choking  is  a 
potentially reversible situation and CPR should 
be commenced if required.  
Staff Training Matrix (names redacted) 

21/10/2024 

23 - 27 

21/03/2025 
31/03/2025 

22/05/2025 

16.07.2025 

– 

28 - 29 

30 

31 

18.08.2025 

32 - 40 

As stated at the Inquest, the management involved are no longer working at Aspray House 
and I would like to assure you their inactions and those of the two nurses on duty on the 
day of the incident in no way reflect the high standard of care that staff at Aspray House 
are trained to deliver. 

The entire staff team have been shocked and saddened by the events that led to the death 
of Mrs Reding and have embraced the training that has been reinforced and continues to 
be reinforced to mitigate the risk of this happening again in the future. 

Mindful of the changes that we have implemented above, and which will be continuously 
monitored and reviewed going forward, we believe that all our residents are appropriately 
monitored,  particularly  dementia  patients  during  mealtimes  who  are  not  left  unattended 
and  are  closely  supervised,  and  that  the  environment  that  they  live  in  is  safe  with  staff 
trained to a high standard. 

We hope we have addressed and allayed the concerns of the Coroner in our response 
above. 

Yours sincerely, 

Operations Manager and RGN

Aspray House Ltd trading as Aspray House. 
Trading Address: 481 Lea Bridge Road, Leyton, London, E10 7EB 
Telephone: 020 8558 9579 | Email: info@asprayhouse.co.uk | Web: www.asprayhouse.co.uk 
Registered Address: 31-33 Commercial Road, Poole, Dorset BH14 0HU (Company Registration No. 04648705)