Safety Alerts

Patient safety alert – Risk of death and serious harm by falling from hoists

https://www.england.nhs.uk/2015/10/30/psa-falling-from-hoists/

Central Alerting System

The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others, including independent providers of health and social care. If you do not already receive these, your organisation will need to subscribe by emailing This email address is being protected from spambots. You need JavaScript enabled to view it. advising that you would like to subscribe to email alerts. This is best completed using a home generic email – see item below for further information on generic emails

Patient Safety Information

Risk of death from asphyxiation by accidental ingestion of fluid/food thickening powder?

NHS England issued a safety alert which will have been cascaded by the Central Alerting System (CAS) in early February 2015. The alert is headed Risk of death from asphyxiation by accidental ingestion of fluid/food thickening powder. This alert is particularly relevant to care settings.

Background Information: Dysphagia (swallowing problems) occurs in all care settings and it is estimated that the condition can occur in up to 30% of people 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. Treatments for dysphagia include changing the consistency of food and liquids to make them safer to swallow. In order to change the consistency of liquid thickness and food texture thickening agents are available in a range of preparations, the most common being a powdered form, supplied in tubs and commonly kept in a place that is accessible such as at the bedside.

Circumstances leading to the Patient Safety Alert: NHS England has 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 this death remains under investigation, it appears the powder formed a solid mass and caused fatal airway obstruction. A further similar incident occurred in a hospital setting: A patient was choking as a result of having taken the lid off a tub of thickening powder and then tipping it back to “drink”. The patient was partially sighted and his condition fluctuated in respect of his conscious alert levels.

Action to be taken:

  • Identify if the accidental ingestion of dry thickening powder has occurred, or could occur, in your organisation
  • 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

View the full alert - NHS England fluidfood thickening powder