“On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team…”
Dated 14 Jan 2020, from the coroner for Black Country. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 10 Mar 2020.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated14 Jan 2020
- Deadline10 Mar 2020
- Published on judiciary.uk8 Feb 2020
- Today22 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Walsall Healthcare NHS Trust | Response publishedPublished on judiciary.uk in February 2020. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
– (1) On the 30/8/18 the deceased had a swallow assessment undertaken at home by the SALT team following a referral by the GP. The recommendations were that a) liquids should be taken in a mildly thick form to slow down the rate of swallow and b) the deceased should follow a soft and bite sized diet. There was no evidence at the inquest that the family had been provided with the definition of ‘bite sized’ in accordance with the International Dysphagia Diet Standardisation Initiative (IDDSI) of 1.5 cm x 1.5 cm. (2) The evidence was that the Eating & drinking plan provided to the family following the assessment did not contain the IDDSI definition of ‘bite sized’. (3) There was no evidence that the family had been provided with a leaflet making reference to the definition of ‘bite sized’. (4) The evidence was that no specific assessment had been undertaken or advice given with regard to bread or bread products despite the knowledge that the deceased would be following an Indian style diet including bread type products including roti and chapatis in accordance with IDDSI guidelines. (5) There was no evidence that advice had been given to the family regarding the deceased’s practice of eating with his hands. The inquest did not find that any of the above matters were causative or contributory to death.
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, 2020-0006
- 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
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