5 December 2018 – Judy Downey, Chair of the Relatives & Residents Association (R&RA) was on the You & Yours programme (Radio 4) on Monday, discussing a distressing death due to choking. Tony, one of our Helpline clients, described how he had discovered his mother being fed with a spoon instead of the syringe that had been prescribed for her and which was specified in her disregarded care plan. The tragic fact is that 70i care home residents died in care homes last year as a result of choking. This figure does not include those who were found choking in care homes and died later in hospital. The causes include poor care plans, care plans which are not followed, unsuitable diets, as well as staff being unaware of residents’ needs, or who do not understand what is required, as well as staff not knowing how to react when someone is choking.
This is a serious and often overlooked risk. Many care home residents – an estimated 50-75% of nursing home residentsii – have conditions which make it difficult for them to swallow, eat or drink. All care home residents should receive an assessment from a specialist.
Speech and language therapists (SALTS) have the skills and training to diagnose and manage the complications caused by swallowing difficulties.iii They can help people to cope better and promote their safety by modifying food and fluids so that the risk of malnutrition and dehydration, as well as that from choking are avoided. It should be normal for all care home residents to receive an assessment from a SALT, and for care staff and families to benefit from their oversight and expertise.
Older people with dementia or following a stroke, as well as those with many other conditions, will generally have swallowing problems. Many will need help to eat and drink and they might also need a special diet. It is essential that care home staff have the time and training to be able to meet these needs.
a different nurse was on duty and immediately noticed that the hose used on the suction device was not appropriate
Unfortunately, we at the R&RA regularly hear accounts of vulnerable residents being placed in danger as a result of poor understanding of their needs. One caller to our helpline complained that her mother had been given a nut roast which she could not eat due to swallowing difficulties and the danger of nuts becoming stuck in her throat. Another found her mother choking on her own saliva. When a member of staff and nurse arrived, they tried using suction to clear it. However, the problem recurred and the relative had to monitor the situation all night. The next morning a different nurse was on duty and immediately noticed that the hose used on the suction device was not appropriate to clear any blockage.
There is currently work underway to try to reduce the risk of care home residents choking. A new initiativeiv has developed an improved system for classifying diets which has been adopted by the British Dietetic Association. This new classification tries to get rid of the confusing description of the ‘soft diet’’ and replaces it with an easier framework.v
This is an important step forward, as according to a recent alert published by NHS England, several patients have come to significant harm over the last two years due to confusion about what is meant by a ‘soft diet’vi. The Care Quality Commission has also issued guidance which care homes should have been using since last April.vii
Relatives and friends need to know that the resident’s care plan should usually include any needs to do with swallowing, eating and drinking, and all staff must be made aware of these and receive the training and supervision to ensure that the risk of choking is minimised.
[i] ONS Office for National Statistics source
[iii] Otherwise known as dysphagia
[iv] From the International Dysphagia Diet Standardisation Initiative (IDDS)
[v] Seven stage framework covering everything from a standard diet to thin liquids. There is a resource page to support implementation of this diet at this address: https://improvement.nhs.uk/resources/transition-to-iddsi-framework/