Man died in hospital after wrongly being fed jelly

An elderly man with swallowing difficulties died by choking in hospital after wrongly being fed jelly.

Milton Keynes Coroner's Court heard that Edward Cassin, 67, should not have been given jelly as it turns to liquid in the mouth and causes choking in people suffering from dysphagia, a condition which causes difficulty swallowing.

Mr Cassin died four days later in Milton Keynes University Hospital on 28 June 2023 as he was waiting to be discharged to a new care home.

Milton Keynes Assistant Coroner, Sean Cummings,  said Edward Cassin’s diabetes had been difficult to manage and there were several alterations to his insulin regime. 

On the 24 June 2023, he had a hypoglycaemic episode requiring treatment and the hospital guidelines were not followed. 

Because of his dysphagia he was on a modified diet and required supervision when eating to mitigate the risk of choking. 

Despite this, there was evidence that throughout his stay he was not properly supervised and was repeatedly fed jelly, highlighted as a food he should not be given, including on the 24 June.

Sean Cummings recorded Mr Cassin’s medical cause of death as aspiration pneumonia, chronic dysphagia and type 2 diabetes.

He concluded Mr Cassin‘ s death was contributed to by neglect and, if he had been treated for the developing aspiration pneumonia, he may not have died.

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 have made meaningful changes to policy and practice to prevent similar incidences happening in the future and will respond to His Majesty's Coroner's Prevention of Future Deaths notice in full."