William Roath

9th December 2025 

For the attention of Mr David Reid 
HM Senior Coroner for Worcestershire 

Dear Mr Reid 

Inquest touching the death of William Roath  
Response to Regulation 28 Report to prevent future deaths 

I am writing in response to the Regulation 28 notice issued following the conclusion of 
the  Inquest  on  13  October  2025  touching  the  death  of  Mr  Roath  who  died  at  the 
Worcestershire Royal Hospital on the 12/12/24.  

We have carefully considered the concerns raised within your report to prevent future 
deaths and would respond as follows. 

University Hospitals Birmingham NHS Foundation Trust was deeply sorry to learn of 
the  death  of  Mr  Roath  following  his  discharge  from  Queen  Elizabeth  Hospital 
Birmingham and transfer to Worcester Royal Infirmary on 28th November 2024.  

The inquest into his death, held 13th October 2025, concluded that Mr Roath died by 
accidental  death  following  a  fall  down  steps….  He  suffered  skull  fractures  and  a 
traumatic  brain  injury  and  went  on  to  suffer  a  number  of  episodes  of  aspiration 
pneumonia. He was transferred to Worcester …. but deteriorated further, most likely 
as a consequence of further aspiration pneumonia. 

The  inquest  heard  that  Mr  Roath  had  initially  been  nil  by  mouth  but  after  an 
assessment  by  the  Speech  and  Language  Team  (SALT)  on  19th  October  2024,  he 
was  cleared  to  receive  a  textured  diet  in  bite  sized  pieces.  Further  concerns  were 
raised  about  Mr  Roath’s  swallow  on  20th October  and,  regrettably,  5  days  elapsed 
before another SALT referral was made. When Mr Roath was reviewed by SALT on 
25th October, his swallow was deemed unsafe. In the intervening 5 days, Mr Roath 
had continued to receive an oral diet intermittently and he had developed and been 
treated  for  a  presumed  aspiration  pneumonia.  He  initially  improved  and  was 
transferred  to  Worcester  for  ongoing  care  but  sadly  succumbed  to  his  illness.  The 
Trust’s  witnesses  highlighted  that  aside  from  his  risk  of  aspiration,  Mr  Roath  had 
remained at significant risk of death as a direct result of his traumatic brain injury and 
its sequelae. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 The inquest heard that UHB had put in place measures to ensure that nursing staff 
and healthcare assistants would not repeat the identified omissions relating to the safe 
management  of  swallowing  problems  and  risk  of  aspiration.  In  the  case  of  medical 
staff,  however,  based  on  the  evidence  presented  at  inquest,  insufficient  action 
appeared to have been taken to prevent a recurrence of this incident. 

University Hospitals Birmingham wishes to assure the court that its policies explicitly 
identify the role of all patient facing staff, including doctors, in managing patients with 
swallowing problems and who are at risk of aspiration. The Trust also has monitoring 
processes  in  place  to  ensure  that  swallowing-related  patient  safety  incidents  are 
identified. 

Responsibilities and monitoring processes are outlined in the Trust Policies: 

Controlled  Document  1201  "Dysphagia  Management  Standard  Operating 
Procedure” (SOP) (Current: April 2023- April 2026) 

6.2.2  Consultant  and  Medical  Team.  All  clinical  decisions  regarding  dysphagia 
management must be agreed by the clinical team, the consultant has overall 
responsibility for the patient’s care. 

Controlled  Document  1209  “Nil  by  Mouth  Standard  Operating  Procedure”  V2 
(Current: April 2023- April 2026) 

Section 4: Implementation and monitoring 

It is the clinical responsibility of the whole team looking after the patient who is 
NBM  (Nil  By  Mouth)  to  ensure  appropriate  and  adequate  nutrition,  hydration 
and  medicine  administration  is  actioned  in  a  timely  way  from  the  point  the 
patient is advised to be nil by mouth. 

Section 11: 

The controlled document lead (Consultant SALT) will lead the audit of the SOP. 
The audit will be undertaken in accordance with the review date and will include: 
• Adherence to the SOP  
• Any untoward incidents or complaints  
• Anything else as appropriate  
•  Patient  Experience  Feedback  (for  example  compliments,  complaints  and 
PALS - where applicable) 

, Consultant Speech and Language Therapist (Dysphagia 
and Altered Airways), leads the audit as a part of the ‘Trust Safer Swallow QIP’ and 
confirms  the  audit  has  been  improved  in  2025  to  provide  more  robust  quality 
assurance.  This  has  included  development  of  a  quality  dashboard,  quarterly  ‘safer 
swallow’ meetings and local audit on local usage of bed signs. The most recent audit 
cycle reviewed the period Jan to Aug 2025. 

 
 
 
 
 
 
 
 
 
 
  
 
 
 Safe  swallowing  falls  within  the  remit  of  the  Trust’s  Nutrition  and  Hydration 
Improvement and Governance Group. Following a review of all Trust Patient Safety 
Priorities (PSP) in November 2025, the Chief Medical Officer & Chief Nursing Officer 
have agreed that Nutrition & Hydration will remain as a Trust PSP in 2026. Leadership, 
membership and Terms of Reference for the Nutrition and Hydration Improvement and 
Governance  Group  have  been  refreshed,  and 
  now  leads  the 
Group. The Nutrition and Hydration Group reports to the Chief Medical Officer & Chief 
Nursing Officer at the Group Clinical Quality Meeting.  

Training of medical staff  

Further, we wish to assure the court that  in the intervening period since Mr Roath’s 
admission, both senior and resident doctors have in fact received training on roles and 
responsibilities  in  relation  to  patients  with  swallowing  problems  including  the 
mechanism by which to refer patients to SALT. 

Specifically: 

1.  Between October 2024 - October 2025, 1141 doctors underwent PICS 

training which specifically details how to request SALT to review a patient 
(data provided a Digital Nurse Specialist in the UHB IT team) 

2.  All consultants joining UHB have undergone training on referral to SALT and 
Dietetics with detailed information on swallow assessment and referral. In the 
last 12 months, at least 83 new consultants have received this training with 
registers kept. 

3.  SALT provide annual training to the “Hospital Preparation Course IPE 
Lecture” (University of Birmingham (UoB)) for final year UoB medical 
students, last provided on June 13th 2025, which includes information on 
referral to SALT. 

Production and distribution of a Patient Safety Notice 

The inquest heard that further Trust-wide communications on SALT referrals were due 
to be delivered to all patient-facing staff. This communication in the form of a Patient 
Safety Notice entitled “Inpatient referrals to the Speech and Language Therapy 
(SLT)  team  across  UHB”  was  distributed  on  7th  November  2025  via  the  following 
,  Deputy  Head  of  Clinical  Governance  and 
means,  as  confirmed  by 
Patient Safety:  

The safety notice has been disseminated via the following methods: 

• 

Intranet: 

•  Uploaded to the patient safety notice page 
•  Front page of ‘The Hub’ (‘latest news’) – UHB’s internal 

Communications platform 

 
 
 
 
 
 
 
  
  
 
 
 •  Radar notice distributed to all ward managers and sisters, Clinical Service 
Leads, governance leads, Clinical Delivery Groups, and all (178) LLS 
Learning Ambassadors (LA’s): 

•  Note: Clinical Service Leads and ward managers are expected to print 

and post on safety boards and share with staff in handovers and 
huddles for a period of two week. 

•  Direct email to: Site Directors of Nursing and Clinical Governance teams 

•  Onward dissemination by others as follows: 

•  Chief registrars – who send via WhatsApp groups 
•  Medical and nursing education teams for inclusion in Resident Doctor 

• 

newsletter 
Inclusion in the ‘Risky Practice’ governance newsletter for UHB 
Emergency Departments 

•  Library team for posting in the Libraries across site 

A Trust-wide staff notice was also sent to all Medical, Allied Health Professionals 
and Nursing teams.  

In summary, we would like to assure you that we consider the omissions in Mr Roath’s 
care at UHB which contributed to his death, as matters of the upmost priority. In the 
intervening year, we have taken steps not only to improve the comprehensive training 
of doctors in relation to recognising and acting upon swallowing problems, but also to 
strengthen the wider clinical governance framework around safe swallowing.  

With best wishes 

Chief Executive  

 
  
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Enclosure: