William Roath
14 Oct 2025 · Coroner David Reid · Worcestershire
The coroner's concerns
1. delayed SALT referral
“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”
2. failure to assess swallowing
“The failure promptly to assess and treat the worsening in Mr. [name redacted] swallowing ability which was identified on 20.11.24 amounted to a failure to provide a basic level of care”
3. continued oral feeding
“Continued oral feeding between 20-25.11.24 contributed to the development/worsening of Mr. [name redacted] aspiration pneumonia which was diagnosed on 21.11.24”