Man dies at hospital after wrongly being fed jelly

An elderly man with swallowing difficulties died in hospital after he was wrongly fed jelly and choked.

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 with people with dysphagia.

He 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.

The trust said it had "made meaningful changes to policy and practice to prevent similar incidences happening in the future".

Assistant Coroner Sean Cummings recorded his medical cause of death as aspiration pneumonia, chronic dysphagia and type 2 diabetes.

He concluded his death was contributed to by neglect and if he had been treated for the developing aspiration pneumonia he would likely not have died at the time he did.

Mr Cummings said his 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 he was repeatedly fed jelly - highlighted as a food he should not be given - through his stay including on the 24 June.

He was not properly supervised and he aspirated.

Caron Heyes, a director at Fieldfisher representing Mr Cassin's family, said: "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."

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