_ The inquest heard that: There was poor understanding by the care home assistants of what was meant by the types of modified diets that could be recommended by the SALT teams. Following Mrs Parker's death both the Local Authority in question and the Care Home provider had taken to improve knowledge within their care homes but it was unclear if there were national programmes to ensure that care assistants understood modified diets and the importance of adherence to them; Within the care home the system for preparing the correct diets types was such that food would come up to be served and would then need to be into the correct format by the care staff. There was no regular system of the kitchen sorting and marking food to be served for individual residents with specific dietary requirements such as Mrs Parker. Following Mrs Parker's death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work in place to ensure care homes and their kitchens ensured clearly marked food was provided for residents with modified diets; In Mrs Parker's case the Inquest heard that there were opportunities to escalate her case back to SALT after choking episodes. However there was limited understanding within care home assistants of the need to report and escalate choking episodes to ensure that the SALT team provided expert input and reduced risk. Following Mrs Parker's death both the Local Authority in question and the Care Home provider had taken steps to improve systems within their care homes but it was unclear if there was national work to ensure that there were appropriate systems in place to ensure that there were appropriate escalations to SALT. ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and believe you have the power to take such action. steps put the

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report; namely by 19"h September 2018. I, the coroner; may extend the period. Your response must contain details of action taken or proposed to be taken, out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION have sent a copy of my repot to the Chief Coroner and to the following Interested Persons namely son of the deceased, who may find it useful or of interetst: Iam also under a duty to send the Chief Coroner a copy of your response: The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: Alison Mutch OBE HM Senior Coroner 25.07.2018 setting