Swallowing referral guidance and first-line safety management

Are you concerned about someone's swallowing? Use the below guidance to help you make a decision on what the next steps are. 

First-line swallowing safety management

These signs indicate likelihood that referral to Speech and Language Therapy for assessment of swallowing may be beneficial. 


  • coughing when eating and drinking
  • wet, gurgly voice
  • throat clearing
  • holding foods and fluids in mouth
  • choking when eating
  • unable to swallow
  • leakage from the mouth

A combination of these signs may indicate a swallowing difficulty. Contact the Speech and Language Therapy Service for advice before referring. 


  • weight loss 
  • slow eating 
  • recurrent chest infections 
  • reluctance to eat or drink 
  • reluctance to eat certain textures 
  • shortness of breath when swallowing
  • dehydrated 

These signs indicate a strong likelihood that a medical review or advice may be needed. 


  • not sufficiently awake or alert to eat and drink 
  • problem swallowing medication 
  • indigestion or heartburn 
  • pain on swallowing 
  • vomiting or regurgitation 
  • feeling full 
  • food sticking (chest area) 
  • nausea after eating or drinking

These signs indicate that other professionals may be able to help. For example, a Dietician, Oral Health Team, Occupational Therapist, Dentist, Nurse, Physiotherapist, Palliative Care. Follow appropriate screening and/or care plans. 


  • mouth is in poor condition 
  • painful teeth 
  • cannot reach drinks 
  • needs eating and drinking independence aids 
  • small appetite 
  • positioning problems 
  • weight loss
  • concerns about oral intake towards end of life

Before referring to Speech and Language Therapy


If the person is sufficiently alert to eat and drink, you can try these strategies. Successful use of these strategies may mean that you do not need to refer to Speech and Language Therapy. Close monitoring is important. 


  • make sure the person is sitting as upright as possible to optimise their swallowing-safety
  • try to keep the head in a neutral position or with the chin tucked-down
  • reduce distractions in the environment e.g. consider turning off the television

Mouthful size

Small sips are generally safer than large mouthfuls. Try a smaller spoon for food.


Wide-brimmed open cups or Kapi-cups (nosey cups) can be useful as these encourage a neutral head position. Avoid using lidded beakers, medicine cups, sport-type bottles, drinking straws and tall or narrow cups.


  • support the person to be as independent as possible but provide partial or full assistance if required
  • encourage small mouthfuls of food and small sips of drinks
  • allow plenty of time between mouthfuls
  • ensure that no food is left in the mouth after meals
  • support with mouth care if required


Complete the oral health assessment tool. Ensure the person maintains a clean, healthy and comfortable mouth.


  • if concerned about choking, discuss, and consider avoiding high-risk foods (dry, crumbly, chewy, fibrous, hard and bread-like products
  • if problems with chewing, discuss, and consider choosing softer or moister foods. You could add extra sauce. Make sure the food given is liked
  • consider whether the person has capacity to decide about their preferred textures of food

If you are still having symptoms

Is the person known to the Speech and Language Therapy Team and do they have swallowing recommendations in place? 

Yes: If there are changes to symptoms or if the person has changed their wishes regarding food or drink, complete the Speech and Language referral form or contact your local Speech and Language Team. 

If the answer is no, refer to the previous swallowing recommendations and contact the Speech and Language Team for advice if required. 

No: Complete the Speech and Language Therapy referral form or contact your local Speech and Language Team.  

To access more information about this resource and the service related to it, you can review the related resources below.

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