Hospital failings contributed to the death of elderly patient in Milton Keynes
An inquest has found that a man with learning difficulties died due to aspiration pneumonia, with his death contributed to by neglect at Milton Keynes University Hospital
Last updated 20th Feb 2025
A coroner has ruled that failings in hospital, under the care of Milton Keynes University Hospitals NHS Trust - contributed to the death of an elderly man with learning difficulties. Edward Joseph Cassin was given food that was unsafe for him to eat and was not properly supervised while in hospital.
The inquest at Milton Keynes Coroners Court heard that Cassin, who had a severe swallowing condition known as dysphagia, was admitted to Milton Keynes University Hospital in May 2023 after a fall. Despite being cleared for discharge, he remained in hospital while awaiting a new care home placement.
On 24 June 2023, Mr Cassin suffered a hypoglycaemic episode which was not managed in accordance with hospital guidelines. Although he was on a modified diet to reduce the risk of aspiration, he was repeatedly given jelly, a food specifically identified as unsafe for him. That day, he was found unresponsive with food and medication left in his mouth, which he had aspirated. He developed aspiration pneumonia and died four days later on 28 June.
Assistant Coroner Sean Cummings concluded that Cassin’s death was contributed to by neglect, stating: "Had his developing aspiration pneumonia been recognised and treated, he would likely not have died at the time he did."
Following the verdict, Cassin’s family criticised the care he received, saying: "We welcome and applaud the verdict and feel vindicated as a family regarding the poor and appalling treatment our brother received which led to his death."
Caron Heyes, a director at Fieldfisher representing the family, said: "When we first looked at this case, we were 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."
Jon Sparkes, Chief Executive of learning disability charity Mencap, described the case as an example of a wider issue in healthcare. "The inquest into Eddie Cassin's death has confirmed his family’s deepest fears; that his premature and preventable death was the result of serious failures in his care," he said. "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 family said Cassin, known as Eddie, was "adored and loved by so many due to his vivacious and kind nature" and that they were left with a "gaping hole in our hearts since Eddie has gone, one which could have been prevented."
A Milton Keynes University Hospitals Trust spokesperson 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. Furthermore, we have made meaningful changes to policy and practice to prevent similar incidences happening in the future.
"We will respond to His Majesty's Coroner's Prevention of Future Deaths notice in full."