Staffordshire and Stoke-on-Trent Integrated Care Board

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First report 1 Jul 2026•Latest report 1 Jul 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Staffordshire and Stoke-on-Trent Integrated Care Board linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Staffordshire and Stoke-on-Trent

    AI-generated summary

    Graham Keith HOLLIS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Graham Keith Hollis, who had dementia and increasing frailty, developed swallowing difficulties and experienced coughing and choking episodes while being fed under an agreed modified-diet plan. He was admitted to hospital with aspiration pneumonia and died on 14 August 2025. The principal concern was that staffing shortages prevented a further face-to-face Speech and Language Therapy assessment, resulting in a best-interests decision to feed him at risk without specialist assessment; safeguards relating to his diet and medical review were also not consistently followed.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of alternative provision when Speech and Language Therapy assessment is absent

    Wider context from the report

    “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. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Staffordshire and Stoke-on-Trent Integrated Care Board; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of Speech and Language Therapy assessments for care home residents

    Wider context from the report

    “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. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026