Much-loved man with swallowing difficulties dies after being wrongly fed jelly at Milton Keynes hospital

Edward Cassin, aged 67, had complex learning difficulties and brain damage from birth but was a much-loved “ray of sunshine” to his siblings, neices and nephews.

He suffered from dysphagia (swallowing problems) as well as type 2 diabetes and was admitted to hospital in June 2023.

But days before he was due to be discharged to a new care home, he had a hypoglycaemic (low blood sugar) episode needing treatment – and the hospital failed to follow guidelines, said Assistant Coroner Sean Cummings.

Edward was fed jelly, which turns to liquid in the mouth and can cause people with dysphagia to choke as fluid goes into the lungs and causes aspiration pneumonia.

He died four days later at the hospital. The coroner recorded his cause of death as aspiration pneumonia, chronic dysphagia and type 2 diabetes.

He said the death was contributed to by neglect and had the developing aspiration pneumonia been treated, his life would likely have been saved.

The inquest heard Edward needed a modified diet and supervision when eating to avoid the risk of choking. But there was evidence that the hospital repeatedly fed him jelly – despite it being highlighted as a food he should not have – and failed to properly supervise him while he was eating it.

It is now expected that the matter is serious enough for the coroner to issue a formal Prevention of Future Deaths notice to the hospital and NHS chiefs.

Caron Heyes from Fieldfisher Law, representing Mr Cassin's family, told BBC news after the inquest: "We were shocked that eight years after Public Health England issued clear guidelines about the dangers of feeding inpatients with dysphagia and learning disability, they are still not recognised in a major hospital."

A spokesperson for Milton Keynes University Hospital NHS Foundation Trust said: "We are profoundly sorry for the failings in Mr Cassin's care. We fully acknowledge the deep distress experienced by Mr Cassin's family and would seek to assure them that we have taken careful steps to understand what happened, including commissioning an independent external review.

"We will respond to His Majesty's Coroner's Prevention of Future Deaths notice in full."

Meanwhile Edward’s family said in a statement to the Citizen: “We welcome and applaud the verdict from HMAC and feel vindicated at as a family regarding the poor and appalling treatment our brother received which led to his death, Eddie was the most vulnerable in our society, one where we placed our faith and trust in MKUH to provide basic care which did not happen as proven in the inquest.

“Whilst Eddie had severe learning disabilities, he was also the beacon that shone through our family, he was adored and loved by so many due to his vivacious and kind nature, Eddie loved nothing more than a party with his family and being sociable. It was so difficult not be feel happy and even elated when he was around and he truly touched the lives of many.

“We now have to move forward with a gaping hole in our hearts since Eddie has gone, one which could have been prevented.”