Neglect verdict in inquest into death of vulnerable man with known swallowing difficulties
Following a two-day inquest in Milton Keynes last week, Assistant Coroner Dr Sean Cummings delivered a neglect verdict after Eddie Cassin died in June 2023 after negligently being fed jelly by nurses at Milton Keynes University Hospital despite having a known problem with swallowing certain foods and liquids.
67-year-old Mr Cassin was admitted to hospital after falling at his care home and at the start of June was fit and waiting to be discharged to a new care home. He had complex medical needs and learning difficulties with known dysphagia (swallowing difficulties) which caused him silent aspiration. He had frequent chest infections/pneumonia as a result.
Because of his dysphagia, Mr Cassin was on a modified diet and required supervision when eating to mitigate aspiration risk. Jelly was specifically and repeatedly highlighted in his notes as a food he should not be given. Despite this, he was repeatedly fed jelly throughout his stay in hospital, including on the 24th June. That day he was generally 'out of sorts' with little appetite.
Because he was not adequately supervised, Mr Cassin was left with food and medication in his mouth, which caused him to aspirate. Medical staff did not recognise this and the coroner concluded it exacerbated his already developing aspiration pneumonia.
The coroner concluded neglect by the hospital and that had Mr Cassin been treated for the developing aspiration pneumonia, he would likely not have died at the time he did.
An independent review conducted in November 2024 into policy and practice around the care of inpatients with vulnerabilities relating to swallowing at Milton Keynes University Hospital found that there have been four deaths in three years at the hospital related to feeding and a fifth case where the patient survived. At least 50% of these involve vulnerable patients.
Caron Heyes represented the family at inquest. She said that investigating the claim, she had been shocked that eight years after Public Health England issued clear guidelines about the dangers of feeding in patients with dysphagia and learning disability, they are still not recognised in a major hospital.
Caron added: "Importantly, this is another case where the doctor listed on the death certificate learning difficulties as a cause of death; this does not represent the full picture. In our view, learning difficulties do not kill people, it's the way those difficulties are inadequately accommodated.
"The coroner removed learning difficulties as a cause of death."
Caron instructed Charley Turton, Andy Roy KC from 12 KBW.
Following the inquest, two of Mr Cassin's sisters said: "We really don't know how to thank Caron for all her support in helping us when our beloved brother died in hospital.
"When we initially spoke to her. she empathised and made us feel that we could achieve a positive outcome at this inquest, we were lost and she helped us navigate through the legal maze of the inquest system. Her expertise in this field was outstanding.
"The team were very focused on the case and provided excellent legal advice and guided us through each process. We achieved more than expected and this was down to our exceptional legal team.
"Many thanks for helping us to get justice for our lovely brother."
Jon Sparkes, OBE, Chief Executive of learning disability charity Mencap highlighted that the charity continues to campaign to end the shocking and avoidable deaths of people with a learning disability.
“The inquest confirmed his family’s deepest fears - that his premature and preventable death was the result of serious failures in his care," he said.
"People with a learning disability are already dying up to 23 years earlier than the general population, with 42% of these deaths being avoidable due to unacceptable barriers to healthcare.
"Yet again, an inquest has exposed multiple failings in the care of a person with a learning disability that have contributed to a preventable death.
"The experiences of people like Eddie must be at the heart of the NHS 10 Year Plan to ensure the government is shaping a healthcare system that truly works for everyone and ends the scandal of avoidable deaths.”
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