title: Care staff perceptions of choking incidents: what details are reported?
abstract: BACKGROUND
  Following a series of fatal choking incidents in one UK specialist service, this study evaluated the detail included in incident reporting. This study compared the enhanced reporting system in the specialist service with the national reporting and learning system.
  
  
  METHODS
  Eligible reports were selected from a national organization and a specialist service using search terms relevant to adults with intellectual disability and/or mental ill health. Qualitative analysis was completed with comparison of themes identified in both sets of reports.
  
  
  RESULTS
  The numbers of choking incidents identified in national reports suggest underreporting compared with the specialist service and varying levels of severity. Themes included trends in timing, care setting and food textures as perceived by staff.
  
  
  CONCLUSIONS
  This study demonstrates paucity of detail in reporting in systems without additional question prompts. Adding these questions requires staff to include greater detail which enables learning and risk mitigation to take place.
authors.affiliation: Specialist Speech and Language Therapist, Lancashire Care Foundation Trust, Research and Development Department, Calderstones Partnership NHS Foundation Trust, Whalley, UK.
authors.forename: Susan
authors.initials: S
authors.lastname: Guthrie
authors.forename: Caroline
authors.initials: C
authors.lastname: Lecko
authors.forename: Hazel
authors.initials: H
authors.lastname: Roddam
mesh_terms: D000328:Adult; D000368:Aged; D000402:Airway Obstruction / Q000453:epidemiology*; D001291:Attitude of Health Personnel; D004435:Eating; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D008607:Intellectual Disability / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D012307:Risk Factors; D012308:Risk Management / Q000706:statistics & numerical data*
keywords: choking; dysphagia; incident reporting; intellectual disabilities; mental illness