SH CP 233

Choking
Managing the risk of choking guidelines
Version: 2

Summary Guidance to reduce the risk of choking for adults with Learning
Disabilities, Mental Health and physical health diagnoses.

Keywords Choking, Dysphagia, Medication, Pica, Swallowing, Cramming,

Risk, Screen, Eating, Drinking, Pacing, Drug

Target audience Frontline staff: , Inpatient services, Community services,

Pharmacists, Pharmacy Technicians, Medics, Nurses,
Psychologists, Occupational Therapists, Physiotherapists, Speech
& Language Therapists, Clinical Support Workers, Non-medical
Prescribers

Date issued July 2019

Approved & Patient Safety Group Date of meeting:

Ratified by 18 April 2019

Next review date July 2020

Author Dr Carol Bailey – Consultant Nurse

Rebecca Edwards – Speech and Language Therapist
Ian Gosling - Speech and Language Therapist
Mary-Helen L’Heureux – North Locality Community Learning
Disability Team Manager
Cate Reeves – Speech and Language Therapist
Juliet Wells – Principal Pharmacist (AMH & LD)

Sponsor John Stagg: Divisional Director of Nursing & Allied Health

Professionals

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Version Control

Change Record

Date Author Version Page Reason for Change

05.10.18 John Stagg 2 4 Further information pertinent to Adult Mental Health
Patients.
7 Further information pertinent to patients with Mental
Health needs such as chronic schizophrenia
9 Further information pertinent to patients with Mental
Health needs such as chronic schizophrenia
13 Updated references.
Transferred onto new template, title change

Reviewers/contributors

Name Position Version Reviewed &

Date
Emma Wadey Deputy Director f Nursing Mental health & Learning V.2 Oct 2018
Disabilities Division
Susanna Preedy Associate Director of Nursing OPMH & Trust AHP V.2 Oct 2018
Lead
Rachel Coltart Associate Director of Nursing & AHP Specialised V.2 Oct 2018
MH Services
Carol Adcock Associate Director of Nursing & AHP AMH V.2 Oct 2018
Services
Aileen Murray-Gane Consultant Nurse OPMH V.2 Oct 2018
Melanie Webb Consultant Nurse – Learning Disabilities V.2 Oct 2018
Richard Illsley Head of Nursing AMH V.2 Oct 2018
Liz James Head of Nursing AMH V.2 Oct 2018
Nikki Duffin Head of Nursing AMH V.2 Oct 2018
Sarah Leonard Head of Nursing AMH V.2 Oct 2018
Laura Pemberton Head of Nursing Specialised Services V.2 Oct 2018
Claire Irvine Speech & Language Therapist Lymington Hospital V.2 Oct 2018
Abigail Hooper Speech & Language Therapist – Learning V.2 Oct 2018
Disabilities
Rachel Middle Speech & Language Therapist - Learning V.2 Oct 2018
Disabilities
Jo Laud Speech & Language Therapist - Learning V.2 Oct 2018
Disabilities
Ian Webster Speech & Language Therapist OPMH V.2 Oct 2018
Emma Ladher Speech & Language Therapist Lymington Hospital V.2 Oct 2018

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 Contents
Section Title Page
1 Introduction 4
1.1 Definition
1.2 Prevalence
1.3 Purpose
1.4 Hazards and Emergencies
1.5 Framework

2. Risk factors and suggestions/guidance for health professional 5

3. Associated Trust documents 11

4. Supporting references 11

Appendices
1. Medicine Considerations in Patients at Risk of Choking 13

2. Flowchart for reporting choking incidents 15

3. SOLENT NHS RISK OF CHOKING SCREEN (for use county 16

and service-wide. Designed to be completed by carers and
service providers)
4. MDT Eating, Drinking and Choking Risk Screen (in LD Clinical 18
Assessment)

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 Choking – managing the risk of choking guidelines
1. Introduction

1.1. Definition
Choking is the introduction of a foreign object (edible or non-edible) into a person’s
airway which becomes lodged and reduces or completely obstructs the airflow to the
lungs. Prolonged or complete choking results in asphyxia, which leads to anoxia and is
potentially fatal.

For the general population choking is a risk whenever food is consumed due to the
closeness of the structures in the throat through which we eat and breathe, and the
close co-ordination of both of these functions. People with a diagnosis of a learning
disability are known to be at a higher risk of choking than other people (Thacker et al,
2007; Samuels et al, 2006). Additional risks for this population include dysphagia; poor
oral health; behaviour such as cramming (overfilling) and self-harm; pica and the side
effects of medication (The Hampshire Safeguarding Board, 2012). Studies of
psychiatric in-patient populations have also shown a significantly increased risk of
choking in patients with chronic schizophrenia (Kulkarni et al 2017).

1.2. Prevalence
In 2007 The National Patient Safety Agency (NPSA) found 605 reports of choking-
related incidents in England and Wales involving adults with a Learning Disability
(between 30th April 2004 and 30th April 2007). Every year people with a learning
disability die from choking while eating and drinking, which could be prevented
(Glover, 2010).

Allen (2012) summarises the prevalence in the mental health population and claims
that there is between an 8 and 20-fold increased risk of choking in patients with mental
illness compared with the general population. (Kulkarni et al 2017) noted that food-
related choking deaths were far more prominent in schizophrenia than in other serious
mental illnesses. Death was related to either acute asphyxia from airway obstruction,
or more insidious aspiration pneumonia.

A systematic review completed by Takizawa in 2016 states that oropharyngeal

dysphagia is a common condition after stroke, Parkinson’s disease (PD), and
Alzheimer’s disease (AD), and can cause serious complications including
malnutrition, aspiration pneumonia, and premature mortality.

1.3. Purpose
The purpose of this document is to provide clear guidance on the roles and
responsibilities of Southern Health NHS Foundation Trust (SHFT) staff within the
management of the risk of choking.

The aim of this document is to ensure safe and effective management for service
users who are at an increased risk of choking.

1.4. Hazards and Emergencies

Anything which may get lodged in the throat is a potential hazard. Whilst food is the
most common cause of choking, other items e.g. medication (see Appendix 1), and
inedible objects can also pose a potential risk.

It is mandatory for all SHFT staff to complete and remain up-to-date with Basic Life
Support training which includes knowing the signs of choking and how to respond if a
choking incident occurs. In addition training providers should be requested to advise

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 on appropriate interventions for people who use wheelchairs or those with a large or
atypical body shape which can make standard response procedures difficult to carry
out.

Appendix 2 states the documentation procedure that should be followed in the event of
a choking incident occurring.

1.5. Framework
This framework attempts to aid the decision making and care planning for staff within
SHFT when working with people with a Learning Disability and/or Mental Health and/or
physical health diagnoses who are felt to be at risk of choking. It aims to assist
clinicians with identifying hazards and risks associated with choking and offer guidance
in what to do about managing these risks.

The aim of this guidance is to minimise the risk of choking and prevent injury, illness
and death.

This guidance should be used in a holistic way with the service user at the centre.
Whenever possible the service user should be involved in the decision making around
their care. If the person does not have capacity to make an informed decision, despite
all reasonable attempts to provide information that is accessible, then decisions should
be made in their best interests which will include their wishes and preferences, and in
consultation with those that know them best.

2. Risk factors and suggestions/guidance for health professional

Risk factor Suggestions/guidance for health professional

Physical - Any significant change in physical health, speech or oral skills should promote a
review of choking.
The person is not able to be Consider:
supported to maintain an  Temporary support to maintain upright stable position.
upright posture with  Physiotherapy advice around posture.
controlled movement and  Occupational Therapy support with specialist
sensation during meals. knowledge of seating and/or adaptive equipment (e.g.
(This may be the result of ‘neater eater’, weighted spoons etc.)
physical disability, injury or  DOLS if mechanical restraint is required.
damage- especially Stroke,  Liaison with Speech and Language Therapy if
Parkinson’s Disease, postural/physical difficulties are impacting on ability to
Huntington’s Disease, manage current diet.
Cerebral Palsy, Tardive
Dyskinesia and other
problems affecting muscle
tone.)
Poor oral health care (for Consider:
example, missing teeth, ill-  Seek dental advice.
fitting dentures) which is new,  Improve mouth care
has increased or where there  Medical/ dental review
is no previous advice.
Level of alertness, e.g. Consider:
having poor or variable levels  Medical review if reason for poor levels of alertness is
of alertness and increase in unknown.
lethargy (this may include  Ensure awake and alert before all mealtimes.
those who have epilepsy, are  Ensure level of supervision when eating/drinking is
‘end-of-life’, who are frail, or

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 who are chronically unwell.)
Known injury or trauma to
neck or throat.
Excessive salivation
Dry mouth/ decreased
salivation
Is generally in poor physical
health
adequate.
 Complete a Malnutrition Universal Screening Tool
(MUST) and liaise with Dietician if there is significant
unplanned weight loss.
 Speech and Language Therapy support if person is
also showing difficulties managing food/drink
consistency.
 Medication (see Medicine Considerations in Patients at
Risk of Choking Appendix 1).
Consider:
 Medical review/ physiological review
 Ensure level of supervision when eating/drinking is
adequate.
 Complete a Malnutrition Universal Screening Tool
(MUST) and liaise with Dietician if there is significant
unplanned weight loss.
 Speech and Language Therapy support if person is
also showing difficulties managing food/drink
consistency.
Consider:
 Medical review/ medication review
 Ensure level of supervision when eating/drinking is
adequate.
 Complete a Malnutrition Universal Screening Tool
(MUST) and liaise with Dietician if there is significant
unplanned weight loss.
 Speech and Language Therapy support if person is
also showing difficulties managing food/drink
consistency.
Consider:
 Medical review
 Treatments for physical health needs
 Augmented and alternative diet and nutrition to support
treatment and recovery.
 Ensure level of supervision when eating/drinking is
adequate.
 Complete a Malnutrition Universal Screening Tool
(MUST) and liaise with Dietician if there is significant
unplanned weight loss.
 Speech and Language Therapy support if person is
also showing difficulties managing food/drink
consistency.

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 Syndrome or physical illness
(e.g. dementia, Prader-Willi
syndrome, pseudobulbar
palsy.)
Epilepsy
Behaviour related
Consider associated risks:
 Look out for signs of deterioration in ability to prepare
food appropriately.
 Look out for deterioration in eating and drinking skills -
consider a referral to Speech and Language Therapy.
 Complete a MUST and liaise with Dietician if there is
significant unplanned weight loss or weight gain.
 Risk of cramming (overfilling mouth) in Prader-Willi
Syndrome (Stevenson et al, 2006).
 Ensure mealtimes are supervised, carers or family are
Basic Life Support trained and use common-sense
approach to preventing access to high risk choking
items.
 Knowledge of the triggers to seizures and ensure to
minimise these at meal times.
 Knowledge of warning signs of a seizure and stop
feeding if there are concerns that seizures may be due
to take place.
 Supporting someone who has food in their mouth
whilst having a seizure (do not attempt to remove
food).
 Stop feeding if service user continues to have
seizures/ poor recovery.
 Be aware of the possibility of vomiting and hence the
risk of choking.

Eating very fast  Ensure level of supervision when eating is adequate.

Cramming food in mouth
Deliberate attempts to block
airway
Distracted whilst eating and
keeps eating.
 Ensure the person has a care plan detailing what
verbal/physical prompts and supervision is needed to
help them to slow down (e.g. verbal reminder, a small
spoon, smaller portions of food).
 Consider discussing with Speech and Language
Therapy.
 Consider functional assessment of the behaviour.
 Ensure level of supervision when eating is adequate.
 Ensure the person has a care plan detailing the
verbal/physical prompts and supervision needed to
support the person to put a manageable amount of
food into their mouth.
 Consider functional assessment of the behaviour.
 Consider referral to Speech and Language Therapy for
eating and drinking assessment.
 Consider liaising with Occupational Therapy around
sensory needs.
 Check the person has adequate supervision.
 Consider functional assessment of the behaviour.
 Refer to Psychology and/or Psychiatry.
 Ensure level of supervision when eating is adequate.
 Look at reducing distractions in the environment
(organisation of room, seating arrangements, noise).
 Check that the person has a care plan detailing what
verbal/physical prompts help them to focus on their
food.

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 Moving around whilst eating
Storing food in the mouth or
food left in the mouth/cheeks
after swallowing.
Abnormal eating and
swallowing habits e.g.
excessively rapid eating and
bolting of food. Taking
inappropriately large boluses
of food. Swallowing without
chewing.
Taking food of a texture that
is beyond their skill level to
manage safely (e.g. taking a
toffee when recommended a
pureed diet)
Taking food when nil by
mouth (eg gastrostomy or NG
fed)
Unmanaged Pica (eating
non-food items).
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 Ensure level of supervision when eating is adequate.
 Ensure the person has a care plan detailing what
verbal/physical prompts support them to sit down
whilst eating.
 Consider liaising with Occupational Therapy around
sensory needs.
 Ensure level of supervision when eating is adequate to
provide prompting to swallow food left in the mouth.
 Consider referral to Speech and Language Therapy for
eating and drinking assessment if prompting is not
successful.
Consider
 Thorough and focussed history taking and physical
examination.
 Multidisciplinary review and treatment as part of risk
management with the patient (whenever possible).
This includes treatment of mental illness, medication
etc.
 Support, aid and help during mealtimes
 Ensure level of supervision when around food is
adequate
 Size and texture of food as well as size of portions.
 Ensure level of supervision when around food is
adequate.
 If the person is not felt to have the capacity to
understand the risks associated with eating un-safe
foods, make sure that a risk assessment and care plan
detailing how to minimise the risk has been completed.
 If the person is felt to have the capacity to decide what
texture they eat consider offering some accessible
information on choking and aspiration. Support the
person to prepare these in a way which reduces risk
(e.g. finely chopping or suggest alternatives).
 Consider liaising with the other members of the team
(i.e. Community Nursing, Psychology) for support
around behaviour that is challenging.
 Ensure level of supervision when around food is
adequate.
 If the person is not felt to have the capacity to
understand the risks associated with eating un-safe
foods, make sure that a risk assessment and care plan
detailing how to minimise the risk has been completed.
 Consider liaising with the other members of the team
(i.e. Community Nursing, Psychology) for support
around behaviour that is challenging.
 Ensure level of supervision is adequate to reduce
immediate risk. Pica can cause choking, small bowel
obstruction, parasite infestations, gastrointestinal
perforations and death.
 Consider the environmental management of Pica (no
dangerous objects available/in reach).
 Check that those supporting the person have a
8

Eating in a non-ideal position,
e.g. lying down.
Regurgitation of food.
Pushing food, fingers or
utensils forcefully to the back
of the mouth.
Secretive bingeing.
Takes a sudden intake of
breath, talks or laughs when
eating.
Excessive rocking during or
just after meals.
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detailed risk assessment and care plan in place.
 Consider functional assessment, analysis and
intervention.
 Consider a nutritional deficiency – liaise with GP.
 Consider liaising with Occupational Therapy re:
enriching environment/sensory needs.
 Consider liaising with the rest of the MDT (Psychology,
Speech and Language Therapy and Nursing).
 Know to whom and how to escalate to if items that are
potentially dangerous (eg batteries, poisons) have
been ingested, and how to manage in the interim.
 Ensure the person is supported and encouraged to sit
in a stable upright position where possible.
 Provide accessible information on posture and eating.
 If the person is unable to achieve a safe position
please refer to Physical section above.
 Consider referral to OT/ physio to look at equipment
and positioning to aid posture and reduce risk.
 Eliminate possible physical health causes. Consider
need for Nursing assessment.
 Seek medical advice (e.g. reflux, oesophageal cancer).
 Liaise with Occupational Therapy around sensory
assessment.
 Liaise with Psychology.
 Ensure the person has adequate supervision to
intervene if required.
 Ensure that a detailed risk assessment and care plan
has been completed detailing how to support the
person to prevent this (e.g. distraction techniques,
removing harmful utensils).
 Consider referral to Speech and Language Therapy for
eating and drinking assessment.
 Liaise with Occupational Therapy around sensory
assessment.
 Ensure the person has adequate supervision to
intervene if required.
 Ensure that a detailed risk assessment and care plan
has been completed detailing how to support the
person to prevent this (e.g. distraction techniques).
 Consider liaising with Psychology and/or eating
disorder service.
 Consider MDT review and care planning with the
patient.
 Consider environmental changes to reduce
distractions. Provide verbal prompts to focus on food.
 If this causes choking, coughing or gagging, liaise with
Speech and Language Therapy.
 Medical advice in relation to the possibility of
reflux/other gastric disturbance.
 Learning Disability only: Liaise with Community LD
nursing (a nursing assessment may be indicated).
 Liaise with Occupational Therapy.
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 Signs and symptoms of dysphagia
Reports of choking on
food/medication.
Reported swallowing
difficulties which are new,
have increased or where
dysphagia management plan
does not meet current needs.
Excessive coughing or
wheezing when eating.
Weak cough or complete lack
of a cough resulting in the
inability to clear the throat of
residue.
Difficulty with chewing or
unable to chew.
Gagging or vomiting on foods
or liquids or lack of a gag
reflex.
Food or liquids coming out of
nose or mouth.
Medication related
Alcohol or drug misuse
Problems with swallowing
medication (e.g. tablets).
Takes medication known to
cause difficulties with
swallowing (i.e. causes dry
mouth, changes in muscle
control, sedation or extra-
pyramidal symptoms).
Compliance
Staff team/carer/family not
following safe eating and
drinking recommendations
(i.e. food texture, pacing,
level of supervision) to
minimise choking risk.
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 Consider referral to Speech and Language Therapy.
 Refer to the Choking Drug Card (Appendix i).
 Consider referral to Speech and Language Therapy.
 Consider medical review if there is a sudden onset or
increase in swallowing difficulties.
 Consider referral to Speech and Language Therapy.
 Medical review.
 Liaise with Physiotherapy around chest status.
 Consider referral to Speech and Language Therapy.
 Liaise with Physiotherapy around breath support.
 Consider referral to Speech and Language Therapy.
 Medical review.
 Consider referral to Speech and Language Therapy.
 Consider referral to Speech and Language Therapy.
 Assess the mental health state, patient’s capacity and
level of alertness.
 Consider level of supervision.
 Consider whether prescribed medication is appropriate
at this time (seek advice from prescriber or Medic).
 Consider service user’s medication review by a
pharmacist, doctor or non-medical prescriber.
 NEVER alter medication (e.g. crush, opening capsules,
mixing medications) without consultation with
Pharmacist or prescriber (this is a legal requirement).
 Please see Choking Drug Card (Appendix i).
 Liaise with a pharmacist, doctor or non-medical
prescriber for medication review.
 Explore the barriers to compliance (e.g. can’t swallow
tablet/s).
 Consider liaising with prescriber around administration
time if medication is felt to be impacting on mealtimes.
 Please see Choking Drug Card (Appendix i).
 Explore the barriers to compliance.
 Ensure carers are aware of dysphagia management
recommendations.
 Mealtime Mat Eating and Drinking Guidelines are in
place.
 Review access to high risk foods.
 Discuss with Adult Social Services to consider need for
safeguarding.
10

The individual is eating foods
which are of a texture that is
against specific SLT
guidance.
 Consider staff training around ‘Eating and drinking
awareness’.
 Access capacity and document this.
 If they have capacity around food textures and risk,
ensure they have accessible information at an
appropriate level and format relating to the risks.
 Support the person to prepare foods in a way which
reduces risk – e.g. finely chop.
 If they do not have capacity to decide to eat these
items against advice, there needs to be a best interest
decision around restricting these items.
 Consider safeguarding, if there appears to be carer
non-compliance around professional advice.

3. Associated trust documents

 SHFT Dysphagia Policy SH CP 130

 Solent NHS Choking Risk Screen (advocated to be used across services by
Hampshire County Council. The form is designed for use by carers, and may lead
to a referral to a Community Learning Disability Team and/or a Speech and
Language Therapist) Appendix iii
 MDT Eating, Drinking and Choking Risk Screen (in SHFT LD Clinical Assessment).
Appendix 4

4. Supporting references

Allen, Diane E.; de Nesnera, Alexander; Robinson, Deborah A. (2012) Psychiatric

patients are at increased risk of falling and choking. Journal of the American
Psychiatric Nurses Association; 18(2), 91-95.

Glover, G. Ayub, M. (2010) How people with learning disabilities die. Improving Health
and Lives: Learning Disabilities Observatory: DoH.

Hampshire Safeguarding Adults Board (2012) Reducing the risk of choking for people
with a learning disability: A Multi-agency review in Hampshire.

Hwang S, Tsai S, Chen I, Hsu F, Li C, Kao, K (2010) Choking Incidents among

Psychiatric Inpatients: A Retrospective Study in Chutung Veterans General Hospital
Journal of the Chinese Medical Association 70, 419-424.

National Patient Safety Agency. (2007). Ensuring Safer Practice for Adults with
Learning Disabilities who have Dysphagia

Stevenson DA, Heinemann J, Angulo M, Butler MG, Loker J, Rupe N, Kendell P,

Clericuzio CL, Scheimann AO. (2006) Deaths due to choking in Prader–Willi
Syndrome. Am J Med Genet Part A 143A:484–487.

Samuels, R. Chadwick, D. (2006) Predictors of asphyxiation risk in adults with

intellectual disabilities and dysphagia. Journal of intellectual disability research 50(5):
362-370.

Thacker, A. Abdelnoor, A. Anderson, C. White, S. Hollins, S.(2007) Indicators of

choking risk in adults with learning disabilities: A questionnaire survey and interview

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 study. Disability and rehabilitation,30(15): 11312-1138.39.

Kulkarni D.P. Kamath V.D. Stewart J.T (2017) Swallowing Disorders in Schizophrenia.
National Center for Biotechnology Information – on line. Springer Science+Business
Media New York (outside the USA) doi: 10.1007/s00455-017-9802-6. Epub 2017 Apr
26. 32:467–471.

Takizawa, C., Gemmell, E., Kenworthy, J. et al. A Systematic Review of the

Prevalence of Oropharyngeal Dysphagia in Stroke, Parkinson’s Disease, Alzheimer’s
Disease, Head Injury, and Pneumonia.Dysphagia (2016) 31: 434.

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Appendix 1 – Medicine Considerations in Patients at Risk of Choking

Patient Review;
 Who is at risk? Higher risk groups include the very young and old, mental health e.g. dementia, stroke, COPD, learning
disability/ID, neurological disease, head and neck cancer.
 Also consider; behaviour (bolting food, pica, cramming, boredom, hunger, taking of food), difficulties swallowing food
(dysphagia) and risk (poor first aid response, poor supervision, and compliance with care plans).
 Consequences of choking; non-adherence with treatment, traumatic experience (loss of trust with HCP), aspiration pneumonia
or death

Legal Aspects to Consider

In the first instance, always try to use a licensed preparation.
Off-label or unlicensed med prescriptions liability rests with the prescriber. The prescriber has
greater responsibility if using an unlicensed product.
It may also rest with the administrator and supplier if they are aware of the unlicensed or off-label
use and were in a position to intervene.
In general, licensed medication may be given in an unlicensed manner only on the instructions of
the prescriber, but local procedures should be taken into consideration. Similarly, care staff may
only give licensed medicines in an unlicensed way if there are written directions in the patient’s
care plan.
Follow the principles of the Mental Capacity Act.
Identify the patient at Risk of Choking

Medication Review Possible signs of

Are all the medicines needed? dysphagia:
Can you change to a different  A choking episode
Use of Thickening Agents  Coughing when
medicine in the same class with
alternative routes available? Which one? eating/drinking
What consistency?  Difficulty chewing
Each product has a different recipe foods
Patient Review for each consistency plus local  Wet/gurgly voice after
 Is there a SLT guidance can alter this swallowing
assessment including SAFETY! Think STORAGE! In the Long Term;
Weight loss, anxiety at
thickening agent Ensure not accessible by
mealtimes, dehydration,
recommendations? the patient recurring chest
 View patient’s care plan. infections/pneumonia
Contact GPre: SLT
referral
If on Modified Diet (following SLT assessment)
1. Always try to use a licensed product
2. Consider liquid, orodispersible or soluble forms Documentation and Advice
3. Consider alternative routes e.g. patches Prescriber – document reason why the
4. Review times of administration
action is taken and discuss this with
5. Allow tablet to disperse in water
patient/carer. Ensure all HCPs are in
6. Crush tablets or open capsules, but be aware this is
off-licence. Consider Health and Safety risks agreement and documented in patient
7. Slow release – do not crush. Consider non-slow medical record and care plan. Inform
release or other medicine or form. Prescription Pharmacy.
frequency may need altering
8. Check for compatibilities (pH sensitive) HCP – inform the patient of what is
9. Use small quantities of cold drinks or food to ensure happening and that medicines are not
the whole dose is taken. being disguised by food but the process
10. Mask bitter medicines with strong flavours . is to aid swallowing. Document in care
11. If on thickened fluids follow SLT guidelines and talk to plan and ensure there are clear
a Pharmacist/Doctor to check how the medicines can instructions on how to administer
be taken with this

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 How to choose a Medicine when a solid form is unsuitable References

 Guidelines: Guideline on the medication management of adults with

swallowing difficulties

 Belfast Trust: How to Reduce the risk of Choking: general advice

 PSS Specialist Pharmacy Service: Supporting patients with swallowing

difficulties: Medicines and Dysphagia (NW London)

 DSS Health Standard 07-1 Guidelines for Identification and Management of

Dysphagia and Swallowing Risks

 NEWT guidelines

 SH CP 30 Medical Emergencies and Resus Policy

 HCC Supporting People at Risk of Choking Policy May 2016

 NPSA 2011

 https://www.medicinescomplete.com/mc/

 https://www.nursingtimes.net/Journals/2012/05/18/i/j/b/120522-med-errors.pdf

 http://www.resourceclinical.com/crushing-tablets-and-drug-administration-via-
enteral-feeding-tubes.html

 https://www.guidelinesinpractice.co.uk/sep_08_wright_dysphagia_sep08?sect
or=professional#.VB866zd0zIU

 http://dysphagia-medicine.com/index.html

 http://www.sign.ac.uk/pdf/sign119.pdf

 https://www.sps.nhs.uk/wp-
content/uploads/2010/01/QA_307_1_Academic_detail_aid_Choosing_medicin
es_for_patients_unable_to_take_solid_oral_dosage_forms.doc

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Appendix 2 – Flowchart for reporting choking incidents

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 Appendix 3 - SOLENT NHS RISK OF CHOKING SCREEN (for use county and service-
wide. Designed to be completed by carers and service providers)

RISK OF CHOKING SCREEN FOR ADULTS

Client Name: …………….………………………………………D.O.B.………….…………..NHS Number:……………………..…………………

Changes to physical health in the last 4 weeks yes / no Changes to mental health in the last 4 weeks yes/ no

Medical diagnoses……………………………………………………………………………………………………………………………………………….

Questions screening the possibility of dysphagia COLUMN A COLUMN B

1. Does the person frequently or continually cough before, during or after eating and/or Yes No
drinking?
2. Does the person have Speech and Language Therapy eating and drinking guidelines? Yes No

Are these guidelines being followed? Give reasons for not following guidelines No Yes
…………………………………………………………………………………………………………………………………………………….
3. Oral skills:
a) Are they able to chew a normal diet? If ‘No’, give details……………………………………………… No Yes
…………………………………………………………………………………………………………………………………………………
b) Is their food and/or drink currently modified? If ‘Yes’, how and why?................................ Yes No
……………………………………………………………………………………………………………………………………………….
4. Has there been a choking (partial or complete obstruction affecting respiratory function)
incident in the last 12 months? Yes No
If ‘Yes’: Number of occasions …………………………………………….…………………………………….………….
What was being eaten? ………………………………………………………..………………………………….…
5. Has the person had pneumonia or recurrent chest infections in the last 12 months?
If ‘Yes’: Number of occasions ………………………………………………………….………………………………… Yes No
Known respiratory conditions……………………………………………………..…………………….….
6. Has there been a significant change in the last 12 months in any of the following: (Please
provide details for any ‘Yes’ responses)
a) Unexpected weight loss………..……………………………………………………………………………………………. Yes No
b) Fluid intake……………………………………………………………………………………………………………………….. Yes No
c) Time taken to complete meal/drink ……………………….Due to problem using cutlery? yes/ no Yes No
d) Self-feeding skills………………………………………………………Due to problem using cutlery yes/ no Yes No
e) Mealtime Environment……………………………………………………………………………………………………… Yes No
7. Does the person have any other behaviours that increase their risk of choking? Yes No

If ‘Yes’, please circle/ provide details e.g. fast pace/food cramming/pushing fingers/ utensils
into mouth/self-harming at mealtimes (not seen at other times)/storing food in cheeks?
Other……………………………………………………………………………...…………………………………………………………
What strategies are in place to manage this behaviour? (prompts/ smaller cutlery etc)
……………………………………………………………………………………………………………………………………………………
Questions that relate to possible choking risks in addition to/ not related to dysphagia COLUMN A COLUMN B
8. Oral Health: Does the person have good oral hygiene/healthy teeth? If ‘No’, please provide No Yes
details……………….………………………………………………………………………………………………………………………..
9. Does the person have a diagnosis of Pica (a persistent craving & compulsive eating of non- Yes No
food substances)?
10. Is the person currently experiencing any of the following side effects from their medication:
relaxed muscle tone; drowsiness; dryness of the mouth; increased saliva? Yes No
If ‘Yes’, please provide details………………………………………………………………..……………………………….
……………………………………………………………………………………………………………………………………………….

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Appendix 3 - SOLENT NHS RISK OF CHOKING SCREEN (for use county and service-
wide. Designed to be completed by carers and service providers)

ACTION: If you have circled answers in column A, an updated care plan, adopting a common sense approach,

may be required to manage the risk of choking. Care plan updated (date)

If you have circled an answer in Column A questions 1-7 liaise with Speech & Language Therapy ENCLOSE THIS
SCREEN.
If the person has a Learning Disability, liaise via MDT Referral made to SLT following liaison Referral to
SLT not required following liaison.
For all other client groups, refer to your local Community Learning Disability Team ENCLOSE THIS SCREEN
WITH REFERRAL

If you have circled an answer in Column A questions 8-10 liaise with appropriate health professional/GP
DON’T refer to SLT
Dentist GP Behaviour specialist other…………………………………………….

Information provided by: _________________Relation to referred person______________________

Contact details for person providing information___________________________________________________

Date completed:

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Appendix 4: MDT Eating, Drinking and Choking Risk Screen (in LD Clinical
Assessment)

ADULT LEARNING DISABILITY

EATING, DRINKING AND CHOKING RISK SCREEN

Client name:………… …………………… Date of Birth:…………. NHS Number:……………………

1. Does the person have eating and drinking guidelines in place? Yes/No
If ‘Yes’ give details:…………………………………………………………………………………………

2. If there are eating and drinking guidelines in place are these being followed? Yes/No
Please give reasons for guidelines not being followed:…………………………………………………
…………………………………………………………………………………………………………………

The following questions relate to signs and symptoms that may indicate a dysphagia
(swallowing difficulty) and/or factors that may contribute to the person being at an increased
risk of choking. If you answer YES to any of the following questions please discuss with the
MDT.

3. Are there any concerns about the person’s ability to eat and drink safely that aren’t being
managed? Yes/No
If ‘Yes’ give details:…………………………………………………………………………………………
………………………………………………………………………………………………………………..

4. Does the person frequently cough before, during or after eating and/or drinking? Yes/No

5. Has there been a choking incident (partial or complete obstruction of the airway) in the last
12 months? Yes/No
If ‘Yes’ number of occasions …………………………………………….………………….………………
On what? ………………………………………………………..…………….….…...................................

6. Has the person had recurrent chest infections or aspiration pneumonia in the last 12
months? Yes/No
If ‘Yes’ number of occasions ………………………………………………………………………………..
Known respiratory conditions……………………………………………….……………………………….

7. Has there been a significant change in the last 12 months in any of the following:
a) Unplanned weight loss Yes/No
b) Fluid intake/signs of dehydration Yes/No
c) Time taken to finish meal/drink Yes/No
d) Self-feeding skills Yes/No
e) Mealtime environment Yes/No
If ‘Yes’ give details……………………………………………………………………………......................
…………………………………………………………………………………………………………………..

8. Does the person have any other behaviours that may increase their risk of choking or aspiration
e.g. fast pace/cramming food/possible self-harm at mealtimes e.g. pushing fingers/utensils into
mouth, orstoring food in cheeks/mouth? Yes/No
If ‘Yes’ give details …………………………………………………………………………………………….
…………………………………………………………………………………………………………………...
If ‘yes’ has the carer attempted prompting/reminding? Yes/No
If ‘yes’ but not successful discuss with Speech and Language Therapist/MDT

10. Oral Health: Are there concerns about the person’s oral hygiene/teeth? Yes/No
If ‘Yes’ give details……………….……………………………………………………………………………..

11. Does the person have a diagnosis of Pica (eating non-food substances)? Yes/No

12. Is the person currently experiencing any of the following side effects from their medication:
relaxed muscle tone; drowsiness; dryness of the mouth; increased saliva? Yes/No
If ‘yes’, please give details……………………………………………………………………………………

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