NHS England Patient Safety Alert: Risk of death from asphyxiation by accidental ingestion of fluid/food thickening powder (5 February 2015)

Summary

Dysphagia (swallowing problems) occurs in all care settings and although the true incidence and prevalence are unknown, it is estimated the condition can occur in up to 30% of people aged over 65 years of age. Stroke, neurodegenerative diseases and learning disabilities can be the cause of some cases of dysphagia, and may also result in cognitive or intellectual impairment, as well as visual impairment, NHS England received details of an incident where a care home resident died following the accidental ingestion of the thickening powder that had been left within their reach.

Whilst it is important that products remain accessible, all relevant staff need to be aware of potential risks to patient safety. Appropriate storage and administration of thickening powder needs to be embedded within the wider context of protocols, bedside documentation, training programmes and access to expert advice required to safely manage all aspects of the care of individuals with dysphagia. Individualised risk assessment and care planning is required to ensure that vulnerable people are identified and protected.

Content

Actions

1. Identify if the accidental ingestion of dry thickening powder has occurred, or could occur, in your organisation.
2. Consider if immediate action needs to be taken locally, and ensure that an action plan is underway if required, to reduce the risk of further incidents occurring.
3. Distribute this alert to all relevant staff who care for children or adults in primary care, emergency care, and inpatient care settings, including mental health and learning disability units.
4. Share any learning from local investigations or locally developed good practice resources by emailing [email protected].