Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0330, written 1 Jul 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 1 Jul 2026 |
|---|---|
| Reference | 2026-0330 |
| Deceased | Graham Hollis |
| Coroner | Kelly Dixon |
| Coroner area | Staffordshire and Stoke on Trent |
| Organisation named | University Hospitals of Derby and Burton NHS Foundation Trust |
| Source | judiciary.uk record |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REPORT TO PREVENT FUTURE DEATHS REGULATION 28 OF THE CORONERS (INVESTIGATIONS) REGULATIONS 2013 Please do not include any living persons’ names in this document, in accordance with the Chief Coroner’s PFD Publication Policy (2026). 1. 2. 3. CORONER I am Kelly DIXON, H M Assistant Coroner, for the coroner area of Staffordshire and Stoke-on-Trent. DATE OF REPORT 01 July 2026 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 4. THIS REPORT IS BEING SENT TO 1. University Hospitals of Derby and Burton NHS Foundation Trust 2. Staffordshire and Stoke-on-Trent Integrated Care Board You are under a duty to respond to this report within 56 days of the date of this report, namely by August 21, 2026. I, the coroner, may extend the period if an appropriate application is made. 5. YOUR RESPONSE Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. I have a duty to send a copy of your response to the Chief Coroner. In accordance with the Chief Coroner’s Publication Policy, you should send me any representations regarding publication of your response. These representations should be made at the same time as the response is provided. I will pass any representations received to the Chief Coroner for a decision. Please note any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. The names of those who do not respond to PFD reports are regularly published on the Chief Coroner’s webpages Non-responses to Prevention of Future Death (PFD) reports - Courts and Tribunals Judiciary. 6. SUMMARY OF CORONER’S CONCERN That the Speech and Language Therapy team were unable to assess care home residents. 7. ACTION SHOULD BE TAKEN In my opinion unless action is taken to address the above concerns then there is a significant risk of future deaths and I believe each of you have the power to take such action. 8. INVESTIGATION AND INQUEST On 08 September 2025 I commenced an investigation into the death of Graham Keith HOLLIS aged 75. The investigation concluded at the end of the inquest on 22 June 2026. The conclusion of the inquest was that: Graham Keith Hollis, aged 75, died on 14 August 2025 at Queen’s Hospital Burton after being admitted from his care home. He had recently been prescribed antibiotics on 30 July 2025 following a suspected aspiration of fluids. He was admitted to hospital after experiencing three choking episodes on 3 and 4 August 2025. Mr Hollis died from aspiration pneumonia, with dementia and frailty of old age contributing to his death. It is not possible to determine what he aspirated on. 9. CIRCUMSTANCES OF DEATH Mr Hollis had significant pre-existing conditions, including dementia, and in the period before his death experienced marked weight loss, reduced mobility and increasing frailty. By late 2024 he developed coughing when drinking and was placed on a Level 4 puréed diet with thickened fluids, which was confirmed as appropriate by the Speech and Language Therapy (SALT) team during a hospital admission in February 2025. During 2025 his weight loss became more pronounced and family raised concerns that he was not tolerating the puréed diet and was refusing food. Despite attempts to obtain a further SALT assessment, this did not take place due to staffing shortages, with advice provided remotely without assessment. At a best interests meeting on 21 July 2025, it was agreed that he would be fed at risk on a supervised Level 5 minced and moist diet, with a plan to revert to Level 4 if concerns arose. Following this change, Mr Hollis initially showed improved engagement with food but remained at risk of choking and aspiration. Between 30 July and 4 August 2025 he experienced a number of coughing and choking episodes, including incidents where he was fed food inconsistent with the agreed diet and where required safeguards, including seeking medical review and reverting to Level 4, were not followed. After a further choking episode on 4 August, he was admitted to hospital and diagnosed with aspiration pneumonia. Although he received treatment, his condition deteriorated and he died on 14 August 2025. The cause of death was aspiration pneumonia, with dementia and frailty contributing; however, it was not possible to determine when, or on what, he aspirated. 10. CORONER’S CONCERNS During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: The Speech and Language Therapy team advised the care home that, due to current staffing levels, the service was unable to undertake assessments of care homes residents, and that this issue had been escalated to the Integrated Care Board. This was the position in July 2025, and the evidence confirmed that it remained unchanged at the time of the inquest in June 2026. In the absence of a SALT face to face assessment and with no alternative provision available, a best interests meeting was convened involving the care home manager, the social worker, the GP Surgery’s care coordinator, and the deceased’s daughter. It was agreed that the deceased would be fed with accepted risk on a Level 5 diet without specialist assessment. 11. COPIES AND PUBLICATION OF THIS REPORT I have a duty to send a copy of my report to every Interested Person who in my opinion should receive it. I also may send a copy of the report to any other person who I believe may find it useful or of interest. I can confirm I have sent the report to: Family Mount Pleasant Residential Home GP Surgery Primary Care Network I also have a duty to send a copy of the report to the Chief Coroner. You may make representations to me, the coroner, about the publication of the contents of this report in line with Chief Coroner’s PFD Publication Policy (2026). Any representations will be sent to the Chief Coroner alongside the report. Please refer to box 4 above for additional information relating to the publication of reports and responses. 12. SIGNATURE Kelly DIXON H M Assistant Coroner for Staffordshire and Stoke-on-Trent
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
HM Assistant Coroner Kelly Dixon Staffordshire and Stoke-on-Trent Coroner's Service Wellington Civic Offices, Larkin Way, Tan Bank, TF1 1LX Monday 17th August 2026 Dear Assistant Coroner Dixon, Regulation 28 Report to Prevent Future Deaths Deceased: Graham Keith Hollis Date of Report: 1 July 2026 Thank you for your Prevention of Future Deaths Report issued under Regulation 28 of the Coroners (Investigations) Regulations 2013 following the inquest into the death of Mr Graham Keith Hollis. The Staffordshire and Stoke-on-Trent Integrated Care Board (ICB) recognises the concerns raised regarding the availability of Speech and Language Therapy (SALT) assessments for care home residents in East Staffordshire and welcomes the opportunity to outline the actions taken and planned in response. Response to the Matter of Concern The concern identified by the Court relates to evidence that the Speech and Language Therapy service was unable to undertake face-to-face assessments of care home residents because of workforce shortages, and that this position remained unchanged at the time of the inquest. The ICB commissions Speech and Language Therapy services from University Hospitals of Derby and Burton NHS Foundation Trust (UHDB) for Care Homes in East Staffordshire and requires providers to maintain safe and effective services for the populations they serve. During the period in question, UHDB experienced significant workforce challenges within the Speech and Language Therapy service which affected its ability to provide assessments to some care home residents. Actions Taken The ICB became aware of the workforce capacity issues through established contract management and oversight arrangements with UHDB. The matter has been reviewed through regular contract meetings and provider assurance processes, with the Trust required to report on service performance, risks and mitigation plans. Whilst recruitment and retention challenges have affected the provider's ability to fully staff the service, interim arrangements have been implemented to ensure clinical support remains available pending restoration of full service capacity. These arrangements include: • Provision of specialist advice and guidance by the Speech and Language Therapy service to care homes through remote support mechanisms, including email advice. • Ongoing escalation routes for complex cases where specialist input is required. • Continued monitoring of service capacity, waiting times and clinical risk through routine commissioner-provider oversight arrangements. • Review of the effectiveness of interim pathways to ensure that care homes continue to have access to specialist advice while workforce shortages are addressed. Future Actions The ICB recognises the importance of timely access to specialist swallowing assessments for care home residents and has therefore: • Continued to hold UHDB to account through contractual performance management processes regarding workforce recovery and service capacity. • Commenced planning for recommissioning of the service within the community, with consideration being given to service resilience, workforce sustainability, responsiveness for care home residents and arrangements for managing periods of reduced staffing capacity. • Ensured that lessons arising from this Prevention of Future Deaths report will inform future commissioning intentions and service requirements for SALT services. Conclusion The ICB acknowledges the Coroner's concerns and recognises the importance of ensuring access to appropriate specialist SALT assessment for care home residents. While the staffing challenges experienced by the provider have not yet been fully resolved, the ICB has maintained oversight through its contractual mechanisms, supported interim advice arrangements to mitigate risk, and is progressing recommissioning activity designed to strengthen the resilience and sustainability of the service in the future. We trust this response provides assurance regarding the actions taken and planned by the Integrated Care Board 2 Yours sincerely, Chief Nursing Officer NHS Staffordshire and Stoke on Trent ICB NHS Shropshire, Telford and Wrekin ICB 3
Ms Kelly Dixon HM Assistant Coroner for Staffordshire & Stoke on Trent 21 August 2026 Dear Madam Re: GRAHAM HOLLIS - Regulation 28 Report Response I am writing in response to the Regulation 28 Report dated 1 July 2026 following the inquest into the death of Mr Graham Hollis. Conscious that Mr Hollis' family will receive a copy of this response, I firstly want to begin by offering my deepest condolences to his family. I note that you have identified concern that due to current staffing levels the Speech and Language Therapy (SALT) team are unable to undertake assessment of care home residents. This was the position in July 2025, and it remained unchanged at the time of the inquest held in June 2026. Such concerns are taken very seriously, and we are continually taking steps to actively address this. I confirm that University Hospitals of Derby and Burton NHS Foundation Trust (UHDB) are commissioned by the South Staffordshire and Stoke on Trent ICB (SSOT ICB) to provide community SALT services to domiciliary settings and residential care homes in East Staffordshire. The UHDB SALT team has been unable to provide face-to-face assessments since January 2025 due to capacity constraints. As a mitigation, the team has continued to provide advice remotely where requested, including via telephone and email. that offered I understand that the inquest heard evidence that in Mr Hollis' case the clinical advice provided by the SALT team by email on 17 July 2025 would not have differed the to recommendations within that email were based on the clinical information available at the time, including the patient's history and established risk factors. I appreciate however that these were based on the established information from his care team rather than upon a physical examination. face consultation had taken place, as if a face to The Trust is continues to actively try to recruit into the team to close this resource gap. These attempts have included ongoing and active attempts to recruit at Band 7 level, which were unfortunately unsuccessful, with applicants withdrawing prior to interview on two separate occasions. There is, unfortunately a shortage of appropriately qualified SALT practitioners and efforts to secure locum staff as an interim measure have also been unsuccessful. We have also been unable to fill this gap from the NHS bank supply. This reflects the wider national context where shortages within the SALT workforce are well recognised We have however been able to make some very recent progress. Upon recent interview we have secured a Band 7 Locum Speech and Language Therapist to deliver the community based activity. Whilst we had attempted to fill with a full time position, the individual concerned is only available 2 days per week. A recruitment process is also currently under way for a Band 6 Speech and Language Therapist with focus on the inpatient service required at Queen's Hospital Burton, including the Samuel Johnson and Sir Robert Peel community hospital sites. The decision to recruit at Band 6 level reflects a revised strategy aimed at improving recruitment success. Interviews were held on 10 August 2026 for a substantive 0.74 whole time equivalent Band 6 professional. Two appointable candidates were interviewed. The team are now exploring if a temporary Band 6 practitioner post can be appointed for the wider SALT team based at Queens Hospital Burton, utilising the potentially remaining 0.6 whole time equivalent Locum funding, to further enhance capacity to deliver the community based activity. This is of course subject to candidates accepting offers of recruitment, but does offer us more positive progress than on previous recruitment drives. It is the Trust's position that ultimately that community SALT services need to be delivered by community NHS providers rather than an from an acute provider. This remains under active discussion with our Integrated Care Board colleagues. The long-term aim is to draw Trust commissioning of the service to a close, but this will need to be done in a safe way with a new provider. To achieve this the Trust is exploring alternative service delivery options and is supported by the ICB. We hope that this response provides assurance that we are doing all we can to improve community SALT services taking account of the constraints involved. Yours sincerely Deputy Chief Executive and Chief Nurse
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