Joan Whitworth

illcare

21st September 2025 Head Office:
Hill Care Group

ANDREW HETHERINGTON 7 oe

HM Senior Coroner for Northumberland Chesterfield

County Hall Derbyshire

Morpeth S41 8NL

Northumberland

NE61 2EF

Dear Sir,

Re : Regulation 28 Report to Prevent Future Deaths PF

In response to your report to prevent future deaths dated 29 July 2025 following the inquest of Joan
Whitworth, please find below the actions taken in relation to the Matters of Concern.

1. Basic Life Support and First Aid at Work

Concerns related to a Registered General Nurse and a Senior care Assistant not being in date with
their training in Basic Life Support and First Aid at Work. There was a further concern listed that
meant it could not be confirmed if an agency care worker was up to date with their training in these
areas.

Actions Taken:

1a. We have changed the electronic platform on which we record staff training since the death of
Joan Whitworth in March 2023. The new platform offers an additional function in that it will alert
the staff member when training is due to expire, meaning timely reminders and arrangements for
refresher training can take place. Further to this, an automated report has been scheduled for the
Home Manager to receive a compliance report at the same time each week in order that they are
fully aware of training that is nearing expiry and can therefore remind staff to complete promptly.

Status — In place

1b. We have added additional checks to our governance systems meaning that Regional Managers

will also check for compliance with mandatory training (that includes refresher training) as part of
their role.

Status — In place

1c. With regard to the agency care worker, we have reviewed the system by which we check the
skills and training credentials of agency workers. Profiles for workers are now received and checked
for each care worker prior to their shift; this now includes the training they have completed and the
dates of completion. Since the inquest, we have reiterated with our agency staff supplier the
mandatory training that is required of their workers and that this must be kept up to date.

Hill Care Holdings Limited

Registered Office: 91-97 Saltergate. Chesterfield, Derbyshire, S40 1LA. Registered in England 08902865

Status — In place

“1d. We have reissued Basic Life Support and IDDSI/Dysphagia training to all staff on the electronic
system and have allocated a specific timeframe in which this training is to be completed. All staff will
have completed face to face emergency first aid training by 14"" October 2025.

Status — In progress with a completion date of 14.10.2025

1e. We have developed and issued a competency assessment to check staff knowledge of IDDSI
diets.

Status — In place and to be completed by all staff by 30.9.25

2. Training

Concerns related to a Senior Care Assistant not being able to recall having received formal training in
the preparation of care plans, no training on MUST or calculating BMI, yet was completing care plans
and documents. A further concern was listed regarding identification of high risk on the Nutritional
Risk Assessment on three prior dates with no referral made to the GP, dietician or consideration of
referral to SALT, and that in the absence of training, there was not an understanding of the
assessment.

Actions Taken:

2a. We can confirm that the Senior Care Assistant had received training as she had previously
undertaken a 12 week Care Home Assistant Practitioner (CHAP) course. However, we acknowledge
that measures were not in place to verify knowledge, nor was a schedule of refresher training in
place to ensure she felt confident to carry out assessments and develop care plans. As a result of
this, we have reviewed the content of the training that we deliver and have a plan for our internal
quality improvement team to deliver training on assessments to nurses and senior care assistants as
a refresher and to build this into our training programme to be repeated on a 3 year cycle. We wil!
monitor this schedule using our electronic training platform.

Status — In progress. Deadline for completion 31.10.2025
3. Agency Staff Induction

Concerns are raised that an agency member of staff remained in the dining room and was last seen
standing next to the alarm bell cord. The care assistant did not intervene immediately when the
deceased showed signs of choking and instead sought help. There is a further concern that it could
not be confirmed if the agency staff had undergone an induction.

Actions taken:

3a. We have reviewed the induction forms for all agency roles that we use in our homes to ensure
that they capture information that allows us to see that agency care assistants have up-to-date first
aid training. For agency senior care assistants and nurses we have modified our form to ensure we
check that mandatory training is in place and in date, and that residents modified diets are discussed

Hili Care Holdings Limited

Registered Office: 91-97 Saltergate. Chesterfield. Derbyshire, S40 1LA. Registered in England 08902865

Status — In place. New forms implemented on 11.9.25

4, Normal Diet IDDSI L7 easy chew and to avoid difficult textures

Concerns were noted that a chef in evidence at the inquest was not aware that breaded fish was not
a suitable food stuff in the diet identified for the deceased. A further concern is identified in that
other residents could be fed inappropriate food stuffs that are not in line with their identified diet
plans.

Actions taken:

4a. A specialist IDDSI training provider has been sourced and face to face training in preparation of
modified foods is being delivered to all Hill Care Cooks and Chefs between the dates 13 September
2025 and 22 October 2025. This training will give chefs and cooks the opportunity to practically
prepare meals of different consistencies and further their knowledge regarding appropriate and
inappropriate foods for specific IDDSI level diets. The chef and cook at The Oaks will attend on 13"
September and 24" September 2025.

4b. We have developed and introduced a competency assessment to all members of the catering
team.

Status — Completed

4c. We have introduced a reference sheet which highlights every residents’ IDDSI level and
additional nutritional needs which is available to all staff on each serving trolley. This form is
reviewed at the daily ‘flash’ meeting to ensure that changes in need are documented without delay.

Status - Completed

4d. Following the death of Mrs Whitworth, we introduced a safety pause before meal times. This
consists of the senior person on duty confirming that the team within the dining room are aware of
any special diets and that the kitchen have provided the correct diet. The Regional Managers
observe this to monitor practice when the visit the home.

Status - Completed

We trust that these measures are sufficient to satisfy your concerns.

Yours sincerely

Managing Director

Enc

Hill Care Holdings Limited

Registered Office: 91-97 Sattergate. Chesterfield, Derbyshire, S46 1LA. Registered in England 08902865

Training & Competency Workbook — Dysphagia, Speech and Language
Therapy (SALT), and the IDDSI Framework

Learning Outcomes

¢ Define dysphagia and describe the oral, pharyngeal, and oesophageal phases of
swallowing.

e Recognise red-flag signs and escalate promptly.

e Explain the role of SALT and when/how to refer.

® Prepare food and drinks to the correct IDDSi level and verify using IDDSI tests.

e Apply safe mealtime management, documentation, and escalation procedures.

¢ Demonstrate competence in texture preparation, Flow/Fork/Spoon tests, and
patient positioning.

Dysphagia

Dysphagia is difficulty moving food/liquid/saliva safely
and efficiently from mouth > throat > oesophagus >
stomach. Problems may occur in any phase.

e Oral phase: Lip seal — keeping lips closed to stop
food or drink leaking out. Jaw movement —
opening and closing to bite and chew, Chewing — breaking food into small, safe
pieces, Bolus formation — mixing food with saliva to make it moist and easy to
swallow (this is called a bofus), Tongue movement — pushing the bolus to the
back of the mouth ready to swallow. Common problems in the oral phase: Poor
dentition — missing or damaged teeth, making chewing hard, Weak tongue —
harder to move food around the mouth, Reduced sensation — not feeling food
properly in the mouth, which can cause food to be left behind or swallowed
before ready.

e Signs to look for: If lips can’t close, food/drink may spill, If chewing or tongue
movement is poor, food may not be safe to swallow ,You might see coughing,
pocketing food in the cheeks, or taking a very long time to eat — these should be
reported to SALT.

Pharyngeal Phase ~ After food or drink is pushed to the back of the mouth, the
pharyngeal phase starts.

e The bolus (chewed food or drink) moves from the mouth into the throat.
« The airway closes so food or drink doesn’t go “the wrong way” into the lungs.
« The voice box (larynx) lifts up to help protect the airway.

Signs to look for: Delayed swallow — food/drink sits in the throat too long before
swallowing starts ,Weak laryngeal elevation — the voice box doesn’t lift enough, making
airway protection harder, Incomplete airway closure — food or drink can enter the
airway (aspiration). These problems increase the risk of choking or aspiration
(food/drink going into the lungs). You might see coughing, wet/gurgle voice, or changes
in breathing after swallowing — these should be reported to SALT immediately.

After food or drink leaves the throat, it enters the oesophagus (food pipe).

Key parts:

« Oesophageal phase: The oesophagus squeezes in a wave-like action (called
peristalsis) to push food or drink down into the stomach. Common problems in
the oesophageal phase: Strictures — a narrowing of the food pipe, which can
make swallowing painful or cause food to get stuck. Reflux — food or stomach
acid comes back up into the throat. Motility problems — the muscles in the
oesophagus don’t squeeze properly, slowing or stopping food from moving to
the stomach.

Signs to look for: Residents with oesophageal problems might say food feels “stuck”
lower down, Resident. may regurgitate food, avoid eating, or eat very slowly, report
complaints of chest discomfort, frequent coughing after meals.

Swallowing Problems — Key Points
How food moves to the stomach
¢ The food pipe (oesophagus) squeezes in waves (peristalsis) to move food/drink
to the stomach.

¢ Problems can include:

Strictures — narrowing of the food pipe., Reflux — food or acid coming back up, Motility
problems — muscles not pushing food properly.

Possible complications if swallowing is unsafe

Food/drink entering the airway (aspiration), Choking, Aspiration pneumonia (lung
infection from inhaled food/drink), Malnutrition (not getting enough food).,
Dehydration (not enough fluid), Emotional and social effects — fear of eating, isolation
at mealtimes.

Common causes of swallowing problems: Neurological (e.g., stroke, Parkinson’s
disease), Structural (e.g., tumours, narrowing), Frailty (weak muscles, poor stamina),
Medication side effects, Other medical conditions (e.g., dementia, respiratory disease).

Red flag warning signs — report immediately: Repeated coughing during or after meals,
Wet or gurgle voice, Reduced alertness or drowsiness, Recurrent chest infections,
Unexplained weight loss, Food feeling stuck.

Signs of swallowing difficulty: Food left in cheeks (pocketing), Chewing for a long time,
Food or drink spilling from the mouth, Frequent throat clearing, Coughing after a delay,
Food/drink coming back up (regurgitation).

Safe mealtime management: Support the resident to sit the person upright at 90°
before, during, and 30 minutes after eating, Keep the environment calm and without
distractions, Slow pacing — allow time to swallow before offering more, Use adaptive
utensils if needed, Follow post-meal care (upright position, check mouth is clear).

Speech & Language Therapy (SALT)

A Speech and Language Therapist is a health professional who helps people with:
Speaking — problems with speech sounds, voice, or fluency.
e Understanding language — difficulty understanding or using words.
e Swallowing (dysphagia) — difficulty chewing or swallowing food and drink safely.

In dysphagia care:
e Assess how well a person can chew and swallow.
¢ | Identify the safest food and drink textures for the resident.
@ Recommend an IDDSI level for food and drink.
e Review progress and change recommendations if needed.

Why SALTs are important in swallowing care:
¢ Help prevent choking and aspiration pneumonia.
e They make sure the person still enjoys food and drink as much as possible while
staying safe.
e They work closely with care staff, nurses, doctors, and dietitians.

When to contact SALT:
e Ifa person starts coughing more at mealtimes.
e = If their voice sounds “wet” or “gurgle” after eating/drinking.
« if they have repeated chest infections.
e If they lose weight or avoid eating.
If they have any new swallowing problems.

IDDSI Food Levels

IDDSI stands for International Dysphagia Diet Standardisation Initiative. It is a global
framework created to make sure that food and drink textures for people with

swallowing difficulties (dysphagia) are described in the same way everywhere — in care
homes, hospitals, and at home.

EASY TO CHEW

SLIGHTLY THICK

{o> —* THIN

DRINKS

Capynght The international Dysphagia Diet Standardisation InBatter 2016
@ bite Midi org Tramawork!

Why it’s important:
e Helps everyone — care staff, chefs, nurses, SALT, and families — speak the same
“language” when talking about safe food and drink textures.
e Reduces the risk of someone getting the wrong texture and choking or
aspirating.
e Makes training and testing food/drink textures consistent.

How it works:
e Food and drinks are divided into levels from 0 to 7.
e Each level has clear testing methods so staff can check that food or drink is the
correct texture.
e Levels 0-4 are for drinks (thin to thick) and also include pureed food at Level 4.
e Levels 3-7 are for food (liquidised to regular).

IDDSI Test

e Fork Pressure Test — For Levels 5-6. Checks if the food can be easily broken
down or squashed with the pressure of a fork.

¢ Spoon Tilt Test — For Level 4. Sample should hold its shape on the spoon and
slide off easily when tilted.

e Fork Drip Test — For Levels 3 and 4. Checks how the sample flows or drips
through the prongs of a fork.

e Flow Test — For drinks and liquidised foods {Levels 0-3). Uses a 10 mL syringe to
measure how much flows out in 10 seconds. ;

IDDSI Food Levels — Clear Guide
Level 3 — Liquidised

Description

Foods that are completely smooth and pourable, with no lumps. They drip slowly in
dollops from a spoon and cannot be eaten with a fork. Used for residents who cannot
chew and have severely reduced tongue control.

How to Test
e Flow Test: 10 mL syringe; after 10 seconds, 8-10 mL remains.
e Fork Drip Test: Drips slowly in dollops through prongs.
© Spoon Tilt’ Test: Food pours off easily, does not hold shape.

Can Have
« Fully liquidised cream soups {no lumps, seeds, or garnishes).
e Seedless smoothies thinned to Level 3 consistency.
e Liquidised porridge with no oat husks (sieved if needed).
e —Liquidised main meals with thick gravy until smooth.

Cannot Have
e Any lumps, seeds, skins, fibres or husks.
@ Mixed-texture soups (with noodles, rice, or chunks).
¢ Thin liquids below Level 3 consistency.
e Gelatin desserts that melt to a thin liquid in the mouth.
e Bread, toast, cereals, or rice (unless fully liquidised to Level 3).

Level 4—- Pureed

Description
Smooth, cohesive foods that hold shape on a spoon. No lumps, skins, or fibres. Does not
require chewing; can be eaten with a spoon, not drunk from a cup.

How to Test ;
© Spoon Tilt Test: Holds shape on spoon, slides off easily when tilted.
e Fork Drip Test: Sits in mound on fork, little or no dripping.
e No lumps visible; smooth texture.

Can Have
e Pureed meat/fish blended with gravy or sauce until smooth.
e Smooth mashed potato blended to non-sticky puree.
e Pureed vegetables and fruits with skins/seeds removed. -
e Thick yoghurt or set custard (meets Level 4 Spoon Tilt Test).

Cannot Have
e Any detectable lumps, skins, fibres, or seeds.
e Sticky, gluey spreads (e.g., thick peanut butter).
® Chunky soups or stews (not pureed}.
« Raw fruits/vegetables.
e Rice, pasta, or bread (unless fully pureed to Level 4).

Level 5 ~ Minced & Moist

Description
Foods that are soft, moist, and minced into lumps 4 mm (adult). Requires minimal
chewing. Lumps must be easy to squash with tongue.

How to Test
e Fork Pressure Test: Lumps squash easily under fork.
. Particle Size: Adult - lumps 4 mm.
e Moist, cohesive, holds shape on spoon.

Can Have
¢ Minced meat/poultry/fish in thick sauce (no gristle/skin).
e Finely chopped cooked vegetables in thick sauce.
e Soft tinned fruits chopped to 4 mm.
© Moist mashed banana mixed with yoghurt.

Cannot Have
e Lumps 4 mm or hard/chewy pieces.
e Dry, crumbly foods (crackers, pastry).
e Stringy/fibrous foods (celery, pineapple).
e Regular bread (unless adapted and texture-tested).
Loose grains like rice or couscous (unless bound).

Level 6 - Soft & Bite-Sized

Description
Tender, bite-sized pieces 15 mm (adult) that require some chewing but are soft enough
to be cut with the side of a fork.

How to Test
¢ Particle Size: Adult — pieces 15 mm.
e Fork Pressure Test: Soft enough to be cut with side of fork.
e. No separate thin liquid around pieces.

Can Have
e Tender meat/poultry cut to 15 mm (no skin/gristle}.
*® Steamed/poached fish without bones or skin.
e Soft cooked vegetables cut to 15 mm.
e Soft ripe fruits (banana, melon, pear) cut to 15 mm.

Cannot Have
e Tough, chewy meats or meats with skin/gristle/bone.
e Hard raw vegetables.
e Fruits with tough skins/pips unless peeled.
e Thick bread crusts or chewy bread.
e Watery soups with floating pieces.

Level 7 —- Regular / Easy to Chew

Description
Normal everyday foods of any texture for those without restrictions, OR softer 'Easy to
Chew' foods for people with minor chewing/swallowing difficulties.

How to Test :
e No specific particle size limits for regular.
e Easy to Chew: Foods should break apart easily with bite pressure.
¢ Avoid very hard, sticky, dry, or stringy foods if Easy to Chew.

Can Have
e Tender casseroles/stews; moist meats; soft cooked veg.
e Soft sandwiches with moist fillings.
e Moist sponge cake and soft puddings.
e Ripe, soft fruits without tough skins/seeds.

Cannot Have
e Very hard, crunchy foods (nuts, raw carrots).
e Sticky/chewy items (toffee, caramel).
e Very dry/crumbly foods.
e  Stringy/fibrous foods without modification.

Safe Mealtime Practices & Emergency Response

Safety Pause .
Purpose: To ensure every meal, snack, and drink given to someone with dysphagia
is safe, correct for their IDDSI level, and in line with Speech and Language Therapist
(SALT) recommendations.

When to Pause
e Before serving food or drink
After any change in a person’s care plan, medical condition, or SALT instructions

Step-by-Step Safety Pause — Nurse in charge, senior care assistant on duty to lead
Confirm the Residents’ IDDSI Level

How to Check:

e Resident landing page on PCS

e Dietary Notification record

e Nutritional PCS report — located in the kitchen

e Prompt cards located on serving trolley

e Dietary Alert Board — Located in the kitchen

e Choking Risk Audit — Located in the kitchen

e Care Plan — PCS

: »
Confirm Safety Pause has taken place by recording on the PCS c,
a

Seating & Positioning for Safety

Before the meal:
e Resident should be fully alert and ready to eat.
e Seated upright at a 90° angle in a well-supported chair or fully upright in bed.
e Feet should be flat on the floor or supported on a footrest.
e Head slightly forward (“chin tuck” position) — never tilted back.

REMEMBER: When serving the meal check the food label on the top of the meal if
Pre-plated by the catering team is the correct IDDSI level has been provided.

During the meal:
e Maintain the upright 90° position.
e Sit close enough to provide support if needed.
Offer small mouthfuls at a steady pace, allowing time to swallow.
Avoid talking while chewing or swallowing.

After the meal:

e Keep the resident upright for at least 30 minutes to reduce aspiration risk.
Check for any food residue in the mouth before they leave the table.

Check the Environment:

e Quiet, calm, and free from distractions.
e Correct utensils and aids in place.

Staff are present at ALL time in the dining room and supervision of residents at
risk during mealtimes, where resident choose to eat their meals in their room and
deemed to be at risk and prescribed a modified diet full supervision is required.

When to Consider Using the LifeVac Device:
LifeVac is a portable, non-invasive airway clearance device designed to help remove
an obstruction from the airway during a choking emergency. It should only be used
by trained and authorised staff and only in specific situations. All Hill Care Home
have a LifeVac located in the dining room area including a poster displayed on its
use.

Understanding the Difference Between Partial and Complete Airway Obstruction:

Partial Airway Obstruction (Mild Choking):

e The resident can still cough, speak, or breathe.

« Encourage them to keep coughing.

e Do NOT use LifeVac at this stage — let them clear the airway naturally.

Complete Airway Obstruction (Severe Choking):

e The resident cannot breathe, speak, or cough effectively.
¢ ‘They may clutch their throat, look panicked, or turn blue.
e This is a life-threatening emergency.

When to Use the LifeVac :

Use only if ALL of the following apply:

e The resident has a complete airway obstruction (unable to cough, speak, or
breathe).

¢ Standard choking protocol has been attempted and failed:

e 5 back slaps. ;

e 5 abdominal thrusts (or chest thrusts if abdominal thrusts cannot be done).

e Alternate back blows and thrusts until obstruction clears or person becomes
unresponsive.

« The resident is still conscious but choking after these attempts.

® You have access to the LifeVac and you are trained to use it.

Do NOT use LifeVac if:
e The person is coughing strongly or can still speak/breathe.
e You are not trained or authorised.

Steps if LifeVac is Needed:

¢ Call for help and ensure 999 has being called.

e Retrieve the LifeVac device from its storage location.

e Assemble the device (mask attached, plunger ready).

¢ Position mask over nose and mouth, ensuring a good seal.

e Push handle down firmly.

e Pull handle up sharply to create suction and remove obstruction.

e Check the mouth and remove any dislodged object.

e Repeat if needed until airway is clear or the person becomes unresponsive.

After Use:

e The resident must be medically assessed even if they seem fine.

© Record the incident on PCS incident reporting record.

e Notify next of kin and follow safeguarding protocols.

e Clean or replace LifeVac components as per manufacturer instructions.

e Report use to your manager to ensure safeguarding alerts are raised and
replacement equipment is arranged.

Training & Preparedness:

e All staff expected to use LifeVac must have training which is allocated by Your Hippo.

e  LifeVac should be stored in an easily accessible, clearly marked location —
dining rooms

DNACPR and Choking Incidents

DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) orders mean that if a

person's heart stops due to a terminal or irreversible condition, CPR is not

performed. :

Choking is different — it is a reversible airway obstruction and requires immediate
intervention.

If Choking Occurs:

e Always intervene using agreed choking response procedures (back slaps,
abdominal thrusts, LifeVac if trained).
e Call emergency services immediately.

Key message for staff:
If a resident is choking, even with a DNACPR order, you must act. Choking is an
acute, reversible emergency.

Patient Safety and Governance Department 
Northumbria House 
Unit 7/8 Silver Fox Way  
Cobalt Business Park 
Newcastle upon Tyne     

NE27 0QJ 

22 September 2025 

IN CONFIDENCE 

Mr A Hetherington 
HM Senior Coroner for Northumberland 
HM Coroners' Office 
County Hall 
Morpeth 
Northumberland, 
NE61 2EF 

Dear Mr Hetherington 

Re:   Report to Prevent Future Deaths – Inquest touching the death of Joan Whitworth 

I am writing to you in response to the Regulation 28 Report to Prevent Future Deaths (PFD) 
served on Northumbria Healthcare NHS Foundation Trust ("the Trust") on 28 July 2025, 
following the inquest into the death of Joan Whitworth. 

Your report was also sent to the Hillcare Group (operators of the Oaks Care Home). I am writing 
to provide you with the Trust response to your concerns. For ease of reference, I have split your 
concern down into the below, constituent parts; the referral and the assessment itself. 

Concern 1: There was no reliance upon the information provided in the referral to SALT 
[Speech and Language Therapy] which identified a concern for Mrs Whitworth's swallow, 
coughing, weight loss, choking. The SALT assessment was based on the verbal account 
of a member of care home staff. 

The  referral  was  made  to  Speech  and  Language  Therapy  by  a  duty  worker  from  Adult  Social 
Care. Ms Whitworth was described in the referral as having advanced dementia. The referral was  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 prioritised  by  the  Trust  SALT  team  as  ‘low  priority’  (according  to  Northumbria  Healthcare 
Foundation  Trust  (NHCT)  SALT  departmental  prioritisation  criteria)  due  to  the  description 
provided of Ms Whitworth’s eating and drinking difficulties and associated risk level. The referral  
stated that she did not want to swallow lumpy food and that she spat out food and drinks. These 
are common, often behavioural, issues associated with advanced dementia and not an indication 
of  an  Oro-pharyngeal  dysphagia.  The  referral  also  states  that  there  had  been  no  episodes  of 
choking.  In  addition,  there  had  been  no  direct  correspondence  from  care  home  staff  to  raise 
concerns, seek advice or request an urgent appointment. 

As  it  was  stated  on  the  referral  that  Ms  Whitworth  was  frail,  had  experienced  a  recent  chest 
infection(s) and that there was increased / frequent coughing, further information was sought from 
a long-standing and experienced Registered Nurse involved in Ms Whitworth’s day to day care at 
The  Oaks  Care  Home.  The  Registered  Nurse  indicated  that  Ms  Whitworth  had  no  swallowing 
difficulties, coughing or choking episodes and that staff had placed Ms Whitworth on a softer diet 
due  to  being  unwell.  This  information,  combined  with  the  referral  information  indicating  a 
protracted oral stage of eating and not a dysphagia, resulted in further face to face assessment 
not being indicated. 

Although the SALT was informed that staff had no concerns regarding Ms Whitworth's ability to 
swallow, the Trust accept that there was a discrepancy in the information on the referral and the 
account of care home staff.  

Following the death of Ms Whitworth and extensive discussion within the wider SALT team, it is 
acknowledged  that  changes  could be made  to  the  electronic referral form,  to  encourage  more 
detailed information from the referrer. These changes, which were referred to during the inquest, 
are due to come into effect in October 2025. 

The planned changes to the electronic referral form can now be detailed as follows: 

1.  The  question  ‘Is  there  increased  /  frequent  coughing?’  will  be  replaced  with  ‘Is  there 
increased  /  frequent  coughing  on  food  and/or  fluids?  and  ‘who  observed  this?’  will  be 
added.  

In  Ms  Whitworth’s  referral,  the  answer  to  this  question  was  ‘yes’  on  the  referral  form, 
however, further discussion with Care Home staff, identified the coughing was likely due 
to a viral infection and/or Ms Whitworth’s recent illness. 

2.  Following the three questions in the online referral form that would indicate a dysphagia 
(below), a mandatory text box will be inserted to allow and ensure the referrer adds further 
detail. 

Increased / Frequent coughing on food and/or fluids? 

• 
•  Frequent chest infections? 
•  Has there been any choking episodes? 

3.  Information on Next of Kin and / or Lasting Power of Attorney (LPA) will be requested on 
the referral form as mandatory, to ensure that SALT will be aware and agree with Care 
Home  staff  who  will  take  responsibility  for  ensuring  the  Next  of  Kin/LPA  are  updated 
following SALT proxy or face to face assessment  (where this is indicated and appropriate). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Concern 2: There was no observation of the Deceased eating and there was no inspection 
of her care records. 

The current expectation and guidance on dysphagia assessments within the Trust and/or 
nationally is set out in the Royal College of Speech and Language Therapists guidance, and all 
SALT staff have undergone robust dysphagia training, which is a post-graduation qualification. 

dysphagia-in-care-homes.pdf  provides  key  strategic  information,  evidence  and  guidance  to 
support discussions with service providers aimed at supporting identification of needs.   Eating, 
drinking and swallowing guidance | RCSLT provides guidance for SALT in the assessment and 
management of people with eating, drinking and/or swallowing difficulties. 

Within Northumbria Healthcare NHS Foundation Trust SALT Department Traffic Light Guidance 
for Managing  Dysphagia  in  a  care home  setting  (shared  with  all Care  Homes)  identifies  SALT 
referral criteria and is based on the above national guidance.  

In Ms Whitworth’s case referral information, it was indicated that she had increased coughing and 
recent  chest  infection(s),  which  met  the  threshold  for  referral to  SALT.  Further  discussion  with 
Care Home staff identified that the increased coughing was likely due to a viral infection and / or 
Ms Whitworth's recent illness. This updated information meant the referral did not meet threshold 
for face-to-face assessment (as per Traffic Light Guidance). 

Following  Ms  Whitworth's  death  and  discussion  of  the  learning  from  this  case,  in  relation  to 
discrepancies  in  referral  information  versus  verbal  reports,  a  Standard  Operating  Procedure 
(SOP) is in development by the SALT department, which is due for sign off and completion by 
October  2025.  This  SOP  will  guide  staff  to  seek  clarification  of  any  discrepancies,  through 
requesting key documents from Care Home staff. In these instances, SALT staff will ask the Care 
Home staff to provide the following: 

•  The Care Home Eating and Drinking Care Plan within the last 3 months; and / or  
•  Choking Incident Risk Assessment within the last 3 months; and / or 
•  The Dietary Intake diary for the last 2 weeks, including notes on swallowing ability.  

In relation to face to face assessment, the SOP will also specify 3 clinical triggers, any one of 
which would indicate a face-to-face assessment is required.  

•  Increased / Frequent coughing on food and/or fluids; 
•  Frequent chest infections; or 
•  Has there been any choking episodes. 

These 3 clinical triggers are also the questions that will be changed in the SALT referral form to 
ensure more information is provided from the outset. 

The SOP also includes prompts to establish with Care Home staff who will liaise with the family 
(where applicable) about the outcome of assessment and ensure the member of Care Home staff 
understands  the  International  Dysphagia  Diet  Standardisation  Initiative  (IDDSI)  level  being 
recommended. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In Ms Whitworth's case, had any concerns been raised regarding her swallow, or incidences of 
coughing  or  choking  on  food/fluids,  the  SALT  would  have  progressed  to  a  face-to-face 
assessment at that time. It should be noted that most patients referred to the SALT service, are 
seen for a mealtime observation, unless no dysphagia is outlined to the SALT involved with their 
care. 

As a Trust, the safety and wellbeing of those we provide service to is paramount and despite the 
unfortunate circumstances in which your concerns have arisen, we welcome the opportunity His 
Majesty's Coroner has provided for us to further address the above issues.  

Yours sincerely 

Chief Executive