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  • Writer's pictureSandra Robinson

Dying for a meal

Updated: Jun 1, 2023

I read the saddest news story this week.

An inquest jury has found that Tony Wilkinson, a disabled man with dysphagia, who choked to death in 2018, was ‘unlawfully killed’.

He choked to death because his support workers did not follow the speech and language therapist’s swallow recommendations of mashed food (this was before IDDSI) and thickened drinks.

Choking can happen to any of us. And it especially increases with age as this U.S. study found. Just look at that graph!

Kramarow, E., Warner, M., & Chen, L. H. (2014).

It’s also interesting to note the percentage distribution of associated causes of death for accidental suffocation by condition in over 65s.

Kramarow, E., Warner, M., & Chen, L. H. (2014).

People with learning disabilities such as Tony are at significant risk of choking.

The incidence of fatal choking incidents of people with learning disability is almost 100 times greater than in the general population (1).

There were 605 reports of choking-related incidents involving adults with learning disabilities over a 3 year period in the UK (2). – 58% took place at mealtimes

and when looking at where they took place;

  1. 41% in care homes

  2. 58% in inpatient settings

  3. 1 % outside either setting

42% of 674 adult service-users with learning disability had one or more choking episodes (3). There was a significantly greater occurrence of choking among people with; – more severe learning disability – with Down syndrome – people who had an incomplete dentition or – were taking a greater number of psychotropic drugs

It’s really important that the speech and language therapist swallow recommendations are followed, that the dysphagia care plan is up to date, and that every single person who supports someone with dysphagia is aware of the recommendations.

The old National Patient Safety Agency produced excellent guidance especially for supporting people with learning disability. It can be found here.

The full story on Tony Wilkinson can be found here.

How to help someone who is choking can be found here.

Our training gives you the theory and practical support you need to ensure that none of the people in your care ever choke to death because the swallow recommendations and their rationale were not fully understood.

  1. Dupont A, Mortensen PB. (1998) Avoidable death in a cohort of severely mentally retarded. In: Fraser W, editor. Key issues in mental retardation research. London and New York: Routledge.

  2. Hampshire safeguarding Adults Board. (2012) Reducing the risk of choking for people with a learning disability. A Multi-agency review in Hampshire. Hampshire County Council Adult Services Department, UK.

  3. Thacker, A. et al. (2008) Indicators of choking risk in adults with learning disabilities: A questionnaire survey and interview study, Disability and Rehabilitation, 30:15, 1131-1138, DOI: 10.1080/09638280701461625


Kramarow, E., Warner, M., & Chen, L. H. (2014). Food-related choking deaths among the elderly. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention, 20(3), 200–203.


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