“1 While Mr”

The coroner’s concerns

– 1 While Mr. Roath was being treated for a traumatic brain injury at the Queen Elizabeth Hospital, Birmingham, a nurse documented on 20.11.24 that he was coughing and spluttering when receiving food and documented that staff were “not to continue to feed patient”. Mr. Roath was then reviewed by a doctor that same day, who documented that there should be a SALT ( Speech & Language Therapy Team ) assessment, but did not record any advice about whether Mr. Roath should remain Nil by Mouth in the meantime. A referral was not made to the SALT team for another 5 days, during which time nursing staff continued to feed Mr. Roath orally. The consultant who gave evidence about the University Hospitals Birmingham NHS Foundation Trust’s ( the Trust’s ) own investigation into this issue told the inquest: (a) Any member of staff can make a referral to the SALT team, and in this case it should have been clearly agreed and set out who would be making the referral recommended on 20.11.24; (b) The reviewing doctor should also have documented that Mr. Roath was to be made Nil by Mouth until a further SALT assessment had been carried out; (c) Continued oral feeding between 20-25.11.24 contributed to the development/worsening of Mr. Roath’s aspiration pneumonia which was diagnosed on 21.11.24; (d) The failure promptly to assess and treat the worsening in Mr. Roath’s swallowing ability which was identified on 20.11.24 amounted to a failure to provide a basic level of care. Having heard evidence from a Senior Sister on Ward 409, where Mr. Roath was treated throughout his admission, I was satisfied that sufficient measures had been taken to try to ensure that nursing and healthcare staff did not repeat the omissions which had been identified at the inquest. When the same question was asked of the consultant in respect of doctors at the Trust, the inquest was told: “a Trust-wide communication will go out to all members of staff that SALT referrals in cases of aspiration can be made by any healthcare professional, and should be made by the professional who recognizes a risk of aspiration.” I am therefore concerned that, so far as doctors at the Trust are concerned, nearly 12 months after the relevant events, no action has yet been taken to try to ensure that the errors made by the doctor who reviewed Mr. Roath on 20.11.24 are not repeated.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2025-0518

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0