Edward Cassin

Executive Office 

31 July 2025 

Sean Cummings  
HM Assistant Coroner for Milton KeynesHM Coroner’s Office 
Civic Offices 
1 Saxon Gate East 
Central Milton Keynes 
MK9 3EJ 

Dear Mr Cummings, 

Re: Regulation 28: Report to prevent future deaths 

Thank you for your Regulation 28 report dated 18 June 2025 following the inquest into the 
death of Edward Joseph Cassin. The inquest concluded on 13 February 2025.   

Central and North West London NHS Foundation Trust (CNWL) deeply regrets the death of 
Mr Cassin and we would very much like to extend our condolences to his family. 

I am writing to provide the Trust’s response to the concerns that you raised in your report.   

Matters of Concern 

A lack of understanding by nursing and other staff of some of the policies and

1.
procedures that the Speech and Language Therapists (SALT) and Dietetic Service had
developed and disseminated for investigating and managing patients prone to aspiration.

Provision of the SALT and Dietetic services by the Central and North West London

2.
NHS Trust into the Milton Keynes University Hospital NHS Foundation Trust (MKUH)
involved both Trusts working to a degree in a siloed manner and that closer co-operation
and sharing of clinical responsibility would benefit patients in a similar position in the future.

We would like to respectfully clarify that the Dietetic Service is provided by MKUH and 
therefore our response refers only to the SALT Service.  With regard to the criticism of siloed 
working arrangements, we have been in discussions with MKUH and have concluded that 
we can improve the service for patients if this is run fully by MKUH.  Arrangements have 
been made with MKUH to transfer the service to them on the 22 October.  We believe this 
change will support more integrated and responsive care, with a single provider responsible 
for coordinating all relevant services within the hospital. CNWL is working closely with MKUH 
to ensure a smooth and safe transition of care. 

Speech and Language Therapists (SALT) policies and procedures 

The SALT Team continue to provide regular training and support to hospital staff on safe 
swallowing to enhance their knowledge and understanding. This training has been reviewed 
to ensure that it provides relevant information to staff about how to identify which patients 
require a referral to the SALT Team, how to make these referrals and how to ensure that 

Trust Headquarters, 350 Euston Road, London NW1 3AX 
Telephone: 020 3214 5700   
www.cnwl.nhs.uk 

 safe swallowing recommendations are followed. The training has been enhanced by the 
inclusion of practical elements such as staff being required to prepare drinks and snacks that 
would be in line with the recommendations for a particular patient.  Staff feedback on the 
training indicates that these changes have been received positively.    

In addition to this, the Speech and Language Therapy team are actively working with MKUH 
on a quality improvement initiative focused on enhancing the care of patients with 
dysphagia.  This has included updating the leaflets describing the International Dysphagia 
Diet Standardisation (IDDSI) levels and in particular providing more specific information 
about the types of food allowed,  as well as making the yellow bedside signs that provide 
patient-specific swallowing recommendations clearer.    

Co-operation and sharing of clinical responsibility 

The SALT Team continue to assess patients on the wards at MKUH and work closely with 
their hospital colleagues as part of this.  A new, electronic, referral process to the SALT team 
has been implemented to ensure that referrals are standardised and can be triaged 
effectively.  In the event of a clinical incident immediate feedback is provided to the ward 
staff.  Any incidents are recorded by CNWL staff on the CNWL Datix incident reporting 
system, they are sent to MKUH within 1 working day and entered into the hospital RADAR 
(incident reporting) system for timely review by MKUH.    

Thank you for bringing your concerns to our attention. I hope that the content of this letter 
provides sufficient assurance that CNWL takes the concerns raised seriously and has taken 
action following the death of Mr Cassin.  CNWL has accepted the points raised and 
continues to work to improve the service we provide.  Should you have any questions or 
comments, please do not hesitate to contact me 

Yours sincerely, 

Chief Executive

4 August 2025 

Dear Dr Cummings, 

REF: Regulation 28 – Report to Prevent Future Deaths 

Thank you for your letter dated 18 June 2025, outlining the details of the Regulation 28 
Report concerning the death of Edward Joseph Cassin, who sadly passed away while under 
the care of Milton Keynes University Hospital NHS Foundation Trust. 
First and foremost, I would like to express my sincere condolences to Mr Cassin’s family. We 
recognise the profound loss they have suffered, and we are truly sorry. I hope this response 
provides assurance that we are taking meaningful and sustained action to prevent such a 
tragedy from occurring again. 
The findings regarding the failings in Mr Cassin’s nursing care do not reflect the standard of 
care I expect from our nursing staff. The deficiencies identified in the management of 
diabetes and dysphagia are unacceptable, and we have taken steps to ensure these are not 
repeated. 
The Regulation 28 Report outlines the following specific actions required by the Trust to 
prevent future deaths: 
•  All staff working with individuals with dysphagia must be knowledgeable about the relevant 

• 

policies and procedures, particularly regarding aspiration prevention. 
Improved collaboration between clinical teams, Speech and Language Therapists (SALT), and 
Dietetics. 

Prior to and following the conclusion of the inquest, the Trust has implemented a number of 
measures to ensure appropriate processes are in place for the care of patients with 
dysphagia. I believe these actions fulfil the requirements set out in the Regulation 28 Report 
and, most importantly, will ensure that patients with dysphagia receive safe, appropriate 
care from well-informed and trained staff. 

Management and Care of Patients with Dysphagia 
The Trust is currently running a Quality Improvement Programme (QIP) focused on 
dysphagia management. This initiative includes collaboration between staff from both 
MKUH and CNWL, working together to strengthen existing practices. 
The QIP has a project charter that outlines the challenges faced by the SALT and MKUH 
teams. The problem statement is as follows: 

“We are seeing a high trend in incidents where patients are choking on food 
or fluids. Swallow assessments are delayed, or advice is not being adequately 
followed, resulting in adverse incidents including aspiration pneumonia and a 
patient death.” 

 
 
 
 
 
 
 
 
 The project has three primary goals: 
1. Improve the quality of SALT referrals. 
2. Provide clear guidance to staff to enhance awareness and management of dysphagia 
prior to referral. 
3. Establish clear service-level agreements and contracts. 

Actions Taken 

Completed: 
•  Established a multi-professional group to develop a dysphagia resource pack for wards and 

departments. 

•  Redesigned and distributed the ‘thickened fluids’ poster in collaboration with SALT, now 

displayed in all inpatient clinical areas. 

•  Ensured all staff are familiar with the poster and understand how to identify and prepare 

• 

appropriate diets. 
Introduced a new electronic SALT referral process, co-designed with CNWL, to standardise 
referral information and improve prioritisation. 

In Progress: 
•  Development of an eating, drinking, and swallowing support kit (available Autumn 2025). 
•  Engagement of a person with dysphagia to support the QIP and training development. The 

Cassin family has been invited to contribute their experience to this work. 
•  Review of current nutritional and dysphagia training (due September 2025). 
•  Refinement of the audit programme to include compliance with special diets (due September 

2025). 

•  Trial of a QR code system to inform catering of patient preferences (September 2025). 
•  Ongoing quality and safety walkabouts focusing on dysphagia management, involving a 

multidisciplinary team. All wards are expected to be visited by October 2025. 

Planned: 
•  Development of a dedicated dysphagia policy (due August 2025). 
• 
•  Design of a referral process for the Emergency Department to access SALT services (due 

Implementation of patient surveys and audits to assess project impact (due September 2025). 

• 

September 2025). 
 Introduction of practical training on special diet textures and preparation (commencing Autumn 
2025). 

Following the inquest, the Chief Nurse issued a ‘call to action’ email to all clinical ward 
leaders, reminding them of their responsibilities regarding diet and fluid management and 
the importance of staff training. This coincided with the release of the updated ‘thickened 
fluids’ posters. 

 
 
 
 The Trust is also investing in new bedside communication whiteboards, designed with input 
from SALT and Dietetics. These boards will highlight individual patient needs, including 
dietary requirements, and are expected to be in place by December 2025. 

Training and Education 
The Trust is delivering a Fundamentals of Care training programme for all clinical staff. Each 
month, a different topic is covered through 7-minute learning sessions and ward-based 
discussions. Topics include: 
•  Oral hygiene 
•  Nutrition and hydration 
•  Recognition of the deteriorating patient 
•  Medicines safety 
• 

Individualised personal care 

The nutrition and hydration module reinforces the importance of special diets and the 
preparation of thickened fluids. All healthcare support workers are also required to 
complete the Care Certificate, which includes training on diet and nutrition. 

Improved Collaboration with SALT 
Since the inquest, the Trust has worked closely with the SALT team to address the 
challenges of delivering care across organisational boundaries. The QIP has identified issues 
such as access to patient records across different systems, and efforts are underway to 
resolve these. 
In April 2025, CNWL served notice regarding the provision of inpatient SALT services. On 9 
July 2025, CNWL began a consultation process with SALT staff to transition the service in-
house at MKUH. While change can be disruptive, we believe this move will improve 
efficiency and ultimately enhance patient care. 
I trust this response provides the necessary assurance that MKUH has acknowledged and 
acted upon the failings identified in the Regulation 28 Report concerning Mr Cassin’s death. 
On a personal note, as the new Chief Nurse, I was deeply saddened by Mr Cassin’s passing. I 
am fully committed to ensuring that incidents of this nature are not repeated, through the 
actions outlined above and by fostering a culture of continuous learning and improvement. 
Yours sincerely, 

Chief Nurse 
Milton Keynes University Hospital NHS Foundation Trust