Choking Risk Assessment

Choking is a serious risk health condition in the UK and around the world affecting more adults above the age of 65 and young ones below the age of 5.

From 2018-2022, the number of death ‘due to choking’ from food and drink (ICD-W79) in England and Wales was 1,118 people (661 Males and 457 females). Also, the report showed that 302 people died due to objects other than food and drinks (ICD-W80 cases) [Data from Office of National Statistics].

As a healthcare provider, it is critical to understand choking hazards and how to assess choking risks for the populations you care for.

This guide covers key information all staff should know about choking risk assessment to help prevent choking incidents and respond appropriately when they occur.

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What is a Choking Risk Assessment?

A choking risk assessment checks how likely someone is to have trouble breathing or swallowing things that could cause harm or suffocation. It looks at their medical history, age, thinking ability, the effects of medications, and other things that might make choking more likely.

Watching how well they eat, swallow, and take care of their mouth also helps determine their risk level.

Who Requires a Choking Risk Assessment?

All individuals in your care should receive a basic choking risk assessment, but pay special attention to:

• Children under 5
• Adults over 65
• Patients with dementia, stroke, Parkinson’s, cerebral palsy, or developmental disabilities
• Those with difficulty swallowing or poor oral health
• Individuals on medications that cause dry mouth
• Anyone with a history of choking incidents or episodes of airway obstruction

Conduct assessments for new patients and reassess if health situations change.

Prompt annual updated assessments even without changes.

The 4 Key Risk Factors for Choking

Healthcare staff should evaluate these four critical risk factors for each patient:

1. Age – As mentioned, those under 5 and over 65 face higher risks.
2. Swallowing Abilities – Note any difficulty swallowing, coughing while eating, pocketing food in mouth, loss of liquid/food from mouth before swallowing. Assess gag reflex. Consider referring patients for swallow evaluations.
3. Oral Health Factors – Check for poor dental health, missing teeth, ill-fitting dentures, dry mouth. All increase chances of choking.
4. Medical History – Focus on stroke, dementia, Parkinson’s, cerebral palsy, developmental disabilities. Also note medications that cause dry mouth as they reduce swallow safety.

In addition to the four key risk areas, ask if the person had any history of gagging, coughing, or choking incidents during meals. Take note of any actions which were performed, like pushing on the belly or using fingers to remove something blocking the airway.

Conduct Regular Reassessments

A person’s condition can change, so it’s important to do new assessments. If there’s a health change due to sickness or injury, re-evaluate all four main risk factors. It’s also good to recheck at least once a year, even if nothing seems different.

Causes of Choking

Choking conditions happen for reasons such as medical conditions or challenges, certain activities or habits exhibited by the individual who is experiencing choking.

For Medical conditions:

1. Brain-related issues: Like Parkinson’s or stroke, which can affect how muscles work, including those used for swallowing.
2. Trouble swallowing: Some people may find it hard to swallow, making it easier for food or drinks to go down the wrong way.
3. Recent surgeries: After operations in the throat or tummy, swallowing might be tricky while healing.
4. Teeth problems: If someone has bad teeth or dentures that don’t fit well, it can make chewing and swallowing harder.
5. Age factors: Very young kids (under 5) and older adults (over 65) might be at higher risk due to their age.
6. Memory issues: Conditions like dementia can make it tough to eat and drink safely.
7. Certain medicines: Some drugs can cause dry mouth or affect muscle control, making choking more likely.
8. Breathing troubles: Chronic lung issues, like COPD or asthma, can make it harder to breathe, increasing the risk of choking.

Choking is a serious risk, especially for those with dysphagia (swallowing difficulties).

A case involving a care home provider in 2017 was prosecuted by CQC (see case here) due to failure in managing the risk, leading to a choking incident. The provider neglected SALT (sensory-motor-oral-myofunctional therapy) advice, failed to update care records, and lacked clarity in staff instructions.

The man’s choking incidents resulted in aspiration pneumonia. The provider was fined (£82,429.72) and urgently closed.

To prevent such incidents, thorough assessments, tailored care plans, and adherence to international standards for dysphagia management are crucial. Public Health England and relevant professional bodies provide guidance.

Common Causes of Choking

In young kids, choking is often caused by small objects like coins, balloons, small toys, and food like nuts, grapes, hot dogs.

For the elderly, common culprits include poorly chewed or oversized bites of food, dentures falling out while eating, and neurological conditions impairing swallowing.

Being reclined while eating, having alcohol before meals, and inhaling food instead of swallowing also up chances of choking for seniors. You can read our article about why choking is more common in care homes.

REAL CASE STUDY 1

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Anthony Gerrard COTTERELL passed away on July 18, 2023, at 50 White Moss Road, Skelmersdale, due to choking on cake. He had been living at the care home since December 2020, and his overall health had declined during this period.

Mr. COTTERELL required his food to be in small pieces and eating to be supervised. However, on July 18, 2023, he was given a whole slice of cake, and though staff were present in the dining room, there was no direct supervision of Mr. COTTERELL’s eating.

Unfortunately, he choked on the cake, and attempts to provide first aid were unsuccessful. 

Source: Lancashire Inquest Conclusion

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General Choking Risk Assessment

Factor	Assessment	Risk Category	Action
Age	< 5 years	High Risk	Provide close supervision during meals, ensure thorough chewing and avoid distractions. Feed soft, moist foods.
—	>65 years	High Risk	Avoid hard, crunchy, or slippery foods. Ensure proper seating position and avoid distractions during meals.
—	Neurological conditions	High Risk	Consult a speech and language therapist (SALT) for dysphagia assessment and recommendations. Follow SALT’s instructions on food preparation and feeding techniques.
Medical history	Swallowing disorders	High Risk	Consult a SALT for dysphagia assessment and recommendations. Follow SALT instructions on food preparation and feeding techniques.
Dental health	Poor oral hygiene	Medium Risk	Regular dental checkups and cleanings to maintain good oral health. Avoid hard foods that may damage teeth or gums.
Dietary needs	Texture, consistency of foods	Medium Risk	Consult a dietician to assess dietary needs and make recommendations on appropriate food textures and consistencies.
Behavior	Talking or laughing while eating	Medium Risk	Encourage focus on eating during meals. Avoid distractions and maintain a quiet environment.
Environment	Loose objects	Low Risk	Regularly inspect the environment for potential choking hazards, such as small toys, coins, or loose objects. Keep choking hazards out of reach.
Food preparation	Hard, crunchy, or slippery foods	Low Risk	Avoid hard, crunchy, or slippery foods that may be difficult to chew or swallow.
Feeding techniques	Fast eating	Low Risk	Encourage slow, deliberate eating to give the body time to properly process food. Allow adequate time between bites.

Child choking risk assessment

Factor	Assessment	Risk Category	Action
Age	Age 0-5	High Risk	Provide close supervision during meals, ensure thorough chewing and avoid distractions. Feed soft, moist foods.
	Age 6-11	Medium Risk	Encourage proper seating position and avoid distractions during meals. Avoid hard, crunchy, or slippery foods.
	Age 12-17	Low Risk	Encourage slow, deliberate eating. Allow adequate time between bites.
Medical history	Swallowing disorders	High Risk	Consult a speech-language pathologist (SLP) for dysphagia assessment and recommendations. Follow SLP’s instructions on food preparation and feeding techniques.
	None	Low Risk	Continue regular feeding practices.
Oral health	Poor oral hygiene	Medium Risk	Regular dental checkups and cleanings to maintain good oral health. Avoid hard foods that may damage teeth or gums.
	Good oral hygiene	Low Risk	Continue regular dental checkups and cleanings.
Dietary needs	Texture, consistency of foods	Medium Risk	Consult a dietician to assess dietary needs and make recommendations on appropriate food textures and consistencies.
	Appropriate texture, consistency of foods	Low Risk	Continue feeding practices.
Environment	Loose objects	High Risk	Regularly inspect the environment for potential choking hazards, such as small toys, coins, or loose objects. Keep choking hazards out of reach.
	Low risk	No action required.
Food preparation	Hard, crunchy, or slippery foods	High Risk	Avoid hard, crunchy, or slippery foods that may be difficult to chew or swallow.
	Soft, moist foods	Low Risk	Continue feeding practices.
Feeding techniques	Fast eating	High Risk	Encourage slow, deliberate eating to give the body time to properly process food. Allow adequate time between bites.
	Slow, deliberate eating	Low Risk	Continue feeding practices.

Additional tips:

• Teach your child to chew their food thoroughly before swallowing.
• Encourage your child to drink plenty of fluids to help them swallow their food.
• Avoid giving your child hard candy, nuts, or seeds.
• Cut food into small pieces and avoid giving your child whole grapes.
• Supervise your child closely during meals and snacks.
• If you think your child is choking, call 999 immediately.

Adult Choking Risk Assessment

Factor	Assessment	Risk Category	Action	Additional Tips
Age	Over 65 years	High Risk	Provide close supervision during meals, ensure thorough chewing and avoid distractions, cut food into small pieces and avoid giving whole grapes, bananas, and apples.	Encourage a slow and mindful eating approach, avoid talking or laughing while eating, and ensure proper seating position.
	Medical history	Swallowing disorders	High Risk	Consult a speech and language therapist (SLT) for dysphagia assessment and recommendations. Follow SLT’s instructions on food preparation and feeding techniques.
	Oral health	Poor oral hygiene	Medium Risk	Regular dental checkups and cleanings to maintain good oral health. Avoid hard foods that may damage teeth or gums.
	Oral health	Good oral hygiene	Low Risk	Continue regular dental checkups and cleanings. Ensure proper chewing and avoid talking or laughing while eating.
	Dietary needs	Texture, consistency of foods	Medium Risk	Consult a dietitian to assess dietary needs and make recommendations on appropriate food textures and consistencies.
	Dietary needs	Appropriate texture, consistency of foods	Low Risk	Continue feeding practices, avoid hard, crunchy, or slippery foods, use pureed or thickened foods as recommended.
	Environment	Loose objects	High Risk	Regularly inspect the environment for potential choking hazards, such as small toys, coins, or loose objects. Keep choking hazards out of reach.
	Environment	Low risk	No action required.
	Food preparation	Hard, crunchy, or slippery foods	High Risk	Avoid hard, crunchy, or slippery foods that may be difficult to chew or swallow.
	Food preparation	Soft, moist foods	Low Risk	Continue feeding practices. Ensure proper chewing and avoid talking or laughing while eating.
	Feeding techniques	Fast eating	High Risk	Encourage slow, deliberate eating to give the body time to properly process food. Allow adequate time between bites.
	Feeding techniques	Slow, deliberate eating	Low Risk	Continue feeding practices. Ensure proper chewing and avoid talking or laughing while eating.
	Talking or laughing while eating	Medium Risk	Encourage focus on eating during meals. Avoid distractions and maintain a quiet environment.	Ensure proper seating position, avoid talking or laughing while eating, and supervise closely during meals.

Research Conducted

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A study conducted by Bronwyn Hemsley et al, reviewed original research on fatal or nonfatal choking incidents in adults, exploring ways to respond to and prevent such incidents.

Using four scientific databases, 52 studies were included, providing insights into factors leading to choking, events during and after incidents, and their impacts.

The findings highlighted various risk factors and recommendations, emphasizing the importance of environmental considerations, appropriate mealtime assistance, oral care, and bystander awareness.

The results could inform policies and training for individuals at risk, their support networks, and the public, with a need for further research on choking prevention in those with dysphagia.

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Conduct Thorough Choking Risk Assessments

When new patients come into your care, assess their medical history, age, medications, and cognitive function to gauge inherent choking risks.

Note any difficulty swallowing, poor oral health, or past choking incidents. Observe eating and consider referring high-risk patients to speech pathologists for swallow evaluations.

1. Do Environmental Sweeps

Check patients’ rooms and common areas for small objects that could pose hazards if mouthed or swallowed.

Ensure toys have age appropriate warnings and parts are over 1.25 inches in diameter. Post choking prevention tips and remove high-risk foods from common dining areas. Educate families on risks.

2. Train Staff in First Aid for Choking

Require all staff to complete Basic Life Support/CPR with a choking response section. Train staff on recognising signs of airway obstruction like clutching throat, difficulty breathing and talking.

Practice delivering back blows between the shoulder blades, chest thrusts, and abdominal thrusts to clear blockages for responsive victims.

Hold refreshers course on CPR/Choking every 6 months.

3. Respond Quickly in a Choking Emergency

If a patient shows signs of choking and can cough, encourage continued coughing while monitoring their ability to breathe. If coughing becomes ineffective, deliver back blows and abdominal thrusts.

Call for medical help immediately if they lose consciousness. For unresponsive victims, begin CPR after a minute of no breathing, clearing any visible blockage first.

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Get More Through Training: Book Our Dysphagia Training for Carers and Nurses

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Prevention is Key

Following comprehensive risk protocols and training staff thoroughly can help avoid many choking incidents.

But when emergencies occur, fast recognition and response through CPR/first aid is critical to preventing fatalities from choking. Reinforce these messages and skills regularly to keep patients safe.

Responding to Choking Emergencies

Quick and effective action is crucial in managing choking emergencies. The steps involved in responding to a choking emergency are:

1. Call for help: Immediately summon emergency medical assistance (999 in the UK) to ensure prompt medical attention.
2. Look, listen, and feel: Check for signs of choking, such as difficulty breathing, coughing, and unable to speak. If you see food or liquid obstruction in the mouth, remove it carefully using a finger or a safe utensil.
3. Back blows and abdominal thrusts: If the individual is unable to cough forcefully, perform abdominal thrusts (Heimlich maneuver) until the obstruction is dislodged and the airway is clear.
4. Repeat the steps: If the obstruction is not dislodged after several rounds of back blows and abdominal thrusts, continue the cycle until help arrives.