A coroner has issued a Prevention of Future Deaths notice to Milton Keynes University Hospital after a pensioner with learning difficulties choked to death on jelly, with medics failing to follow dietary guidelines. Edward Cassin, 62, who suffered from dysphagia and required supervision while eating, died on June 28, 2023, four days after being admitted following a hypoglycaemic episode.
Milton Keynes Coroner's Court heard that Mr Cassin was given jelly throughout his stay, despite it being listed as a food he should not receive due to his condition. The jelly turned to liquid in his mouth, leading to aspiration pneumonia. Assistant Coroner Sean Cummings ruled that neglect partly caused his death, stating that had he received adequate and timely treatment, he would not have died.
Mr Cassin, who had brain damage since birth and type 2 diabetes, was awaiting discharge to a care home. His family expressed shock that guidelines from Public Health England, issued eight years prior, were not followed. They described him as “adored” and “the beacon that shone through our family,” adding that his death “could have been prevented.”
A hospital spokesperson apologised, saying: “We are profoundly sorry for the failings in Mr Cassin's care. We fully acknowledge the deep distress experienced by his family and have commissioned an independent external review.” The coroner's notice calls for action to prevent similar deaths.
