Graham Keith HOLLIS · Prevention of Future Deaths report

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.

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.

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.