Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don't want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue – what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
Denture adhesive gel can be a choking risk due to its thick consistency. It can become lodged deep in the respiratory system and can be difficult to remove. These gels are likely to be used by the older generation and those suffering from a decline in brain function. The packaging and instruction leaflets of these products do not always include a warning for the risk of choking.
For these reasons, adhesive gels should be considered as part of any risk assessment.
Incident of choking
In August 2022, a man was diagnosed with dementia and took up residence in a specialised care home. In June 2024, a member of staff found the man in his room with denture adhesive gel in his mouth, ears, and nose.
Paramedics tried to remove the gel with a suction machine but were unsuccessful. He was taken to hospital where his health deteriorated and he died the same day.
Action taken by CQC
CQC has specific criminal enforcement powers when avoidable harm has occurred. We reviewed the incident in line with our specific incident guidance to establish if there were failings in care.
We found the man's death was not the result of avoidable harm resulting from a registered person or provider failing.
Action taken by the provider
The provider investigated the circumstances of the man's death. The findings conclude that the man had been safely managing his oral health care since his admission in 2022, and there was no specific risk assessment for the management of adhesive gel. As part of the investigation, the provider reviewed lessons learned.
Actions planned by the provider include:
- organisational sharing about the circumstances of the man's death to raise awareness
- identifying residents who use denture adhesive products, or similar, with a view to review documentation and safety measures.
What you can do to avoid this happening
We advise you to consider adhesive gel in the following risk assessments:
- Health and Safety Executive's Control of Substances Hazardous to Health (COSHH) risk assessment, in accordance with COSHH regulations 2002.
- Risk assessments that relate to the health, safety and welfare of people using services, in accordance with Regulation 12: Safe care and treatment.
- Risk assessment for oral health in line with National Institute for Health and Care Excellence guidance.
We also advise you to consider:
- different types of denture adhesives on a case-by-case basis, for example: strips, powders, and creams
- existing guidance that relates to dementia and oral health, such as Dementia UK - mouth care and oral health for people with dementia.
Learning from safety incidents
Each of these pages describes a critical issue: what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.