Colin Brown

Medical Governance 
The York Hospital 
Wigginton Road 
18 February 2026                                                                                                                    YORK 
YO31 8HE 

Ms Gillian Kane                                                                                    
Assistant Coroner for the coroner area                                           
of North Yorkshire & York                                                                         
Ms Gillian Kane 

Dear Madam 

Thank you for raising your concerns following the inquest surrounding the death of Mr Colin 
Brown and his treatment at York Hospital.  We are sincerely sorry that Mr Brown died whilst in 
our care and offer our heartfelt condolences to his family. York & Scarborough Teaching 
Hospitals NHS Foundation Trust (the Trust) recognises the seriousness of your concerns 
outlined at Section 5 of the Report to Prevent Future Deaths (PFD) in relation to ongoing 
swallowing and choking risks for patients presenting to the Emergency Department.  
Following further review of this case I write to outline our response to your concerns.  

Following this incident an immediate action was implemented ensuring that patients in the 
Emergency Department are not given food without the oversight of a registered nurse. This is 
continuing and there have been no further similar incidents.  

Additional mitigations are being considered around the type of food and availability in the 
Emergency Department, with consideration around foods that are considered to present a 
higher risk of choking. Discussions are underway involving Catering Services and the Trust 
Food, Nutrition and Hydration Steering Group.  

Where new concerns are identified about a patient’s swallowing ability, the Trust has a 
Standard Operating Procedure (SOP) for Sip Testing in place along with training. This 
provides staff with guidance around how to complete a sip test to determine whether the 
patient is safe to eat and drink normally. If they fail the sip test e.g. due to coughing, no 
swallow, delayed or multiple swallows then they are referred to the Speech & Language 
Therapy (SALT) team for further advice and assessment to determine the most appropriate 
diet options for the patient.  

 
 
 
 
 
 
 
 
 
 
 
 
 We follow principles of safe handover practice and balance all information received with the 
immediate emergency needs of the patient. If we are in receipt at handover of information 
regarding a significant risk such as severe previous swallowing difficulties or choking risk this 
will be considered within the assessment of any immediate care needs to help manage the 
emergency situation. Action will be taken which is proportionate to the patient’s clinical needs 
in balance with what is operationally deliverable in a busy Emergency Department. Such a 
significant risk would be recorded in the patient’s record to ensure continuity of care 
throughout the patient’s journey.  

The introduction of the Trust’s new electronic patient record (Nervecentre) is being rolled out 
from next month with expected completion in the autumn. This will include the option to have 
a prominent alert to highlight if a patient has a previously identified swallowing difficulty 
recorded in the system and what their recommended texture-modified diet should be. This 
information will therefore be clearly available at future attendances.  

We hope that this information provides you with assurance that the Trust has taken your 
concerns on board and is working to establish improved safety in this area.  

Yours faithfully  

Medical Director & Responsible Officer 

2

06 February 2026 

Ms Gillian Kane 

HM Assistant Coroner for North Yorkshire and York 

Springhill 2 
 Brindley Way 
Wakefield 41 Business Park 
Wakefield  
WF2 0XQ  

Dear Ma’am 

Re: Inquest touching the death of Mr Colin Brown  

I write on behalf of Yorkshire Ambulance Service NHS Trust (YAS) and in response to the 
Regulation 28 report on this matter, issued on 23 December 2025. 

I am aware of the circumstances of Mr Brown’s tragic death and take this opportunity to 
offer my sincere condolences. 

I understand that this Regulation 28 report was issued in circumstances whereby YAS was 
not an Interested Person at the inquest, and I also note that no YAS witness was 
summoned to attend. Due to this, I have no knowledge of the oral evidence given but am 
grateful that YAS has been provided with disclosure post inquest to assist with the 
preparation of a response.  

I am also aware that the YAS at a corporate level was not formally sighted on the Patient 
Safety Incident Investigation conducted by York District Hospital. This has been reviewed 
internally, and steps are being taken to strengthen escalation and notification routes to 
ensure appropriate organisational awareness and oversight in future cases. 

Your matter of concern was: “During the inquest I heard evidence that confirmed that a 
copy of Mr Brown's care plan was not transported with him to hospital. There was mention 
in the notes from Yorkshire Ambulance Service (YAS) that Mr Brown was a choking risk 
but there was a delay of approximately 25 minutes between Mr Brown being verbally 
handed across to hospital staff and the YAS Electronic Patient Form being uploaded to the 
Core Patient Database and accessible to staff dealing with Mr Brown. Such a delay is 
usual and inevitable in these circumstances, allowing time, for example, to access a device 
to action the upload. However, during this 25 minutes the only information that is available 
is what is shared orally in the handover and noted down by hospital staff. This may not 
include reference to a patient being a choking risk either because it is not mentioned by the 
ambulance crew or, because it is not deemed necessary by the hospital staff to check or to 
note, particularly in circumstances where this is entirely unrelated to the presenting 
concern. The evidence before me was that a patient being a choking risk is not routinely 

www.yas.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 checked during all handovers. It was accepted in evidence that patients may not reliably 
draw attention to this crucial information themselves, as was the case here.” 

YAS acknowledges your concern that information relating to a patient’s swallowing or 
choking risk documented within the electronic patient record (ePR) may not always be 
reliably available to receiving hospital teams at the point of initial handover, particularly 
where such information is not directly related to the presenting complaint and where there 
is an unavoidable delay before the ePR is uploaded and accessible. 

We recognise that patients themselves may not always be able to reliably advocate for 
such risks and that reliance on verbal handover alone introduces potential variability. 

To address this, I have taken advice from YAS’s Associate Director of Paramedic Practice 
and asked that we carefully consider the matters of concern raised. I am informed as 
follows:  

Background  

“Mr Brown’s conveyance was managed as a routine (non–pre-alerted) ambulance arrival 
for assessment of suspected acute limb ischaemia, having been assessed by the attending 
clinician as not requiring a pre-alert call, primarily based on the presence of pulses in the 
affected limb as per their documented assessment. National guidance jointly issued by the 
Royal College of Emergency Medicine (RCEM) and the Association of Ambulance Chief 
Executives (AACE) is clear that pre-alert calls should be reserved for patients where the 
receiving Emergency Department must prepare a different or specialised predetermined 
response, and that information-only (also known as “courtesy”) calls should be avoided 
due to information overload and pre-alert fatigue. 

“Accordingly, the transfer of information in this case occurred through standard structured 
verbal handover supported by subsequent electronic documentation (the electronic Patient 
Record (ePR)). Handover of non-pre-alerted patients from an ambulance crew to the 
Emergency Department should be completed following locally agreed processes, ideally 
within 15 minutes of arrival, as per NHSE’s ‘Guidance for emergency departments: initial 
assessment’.  

“National NHS England guidance is explicit in defining responsibility, stating the following: 

‘Responsibility for patient clinical assessment and treatment lies with the hospital from the 
point the ambulance arrives at the department. Ambulance clinicians need to return to their 
vehicle immediately after handover to prepare and make themselves available for patients 
needing an ambulance response in the community’.  

“The ambulance crew provided a structured verbal handover in line with national guidance, 
focused on the presenting complaint of suspected acute limb ischaemia, the patient’s 
physiological status, observations, and immediate clinical risks. The paramedic described 
in a statement that ‘we handed over his past medical history including his neurological 
problem, difficulty swallowing, previous skin cancer as he had a wound on his head’. 

 
 
 
 
 
 
 
 
 “The information I have been provided shows the attending crew reported that Mr Brown 
did not disclose any requirement for a modified or soft diet to them, nor was any care plan 
or supporting documentation reported as existing or being provided, despite care notes 
within the bundle provided by HM Coroner stating Mr Brown required a modified diet. 
Furthermore, a collateral history was not obtainable as no carers or family members were 
at the scene. The ePR completed by the crew does include a past medical history entry 
noting previous swallowing difficulty. This reflects historical medical background obtained 
through them accessing the Summary Care Record for Mr Brown. This is part of routine 
history-taking and information gathering rather than identification of an active or clinically 
apparent risk at the time of ambulance assessment.  

“Mr Brown was alert, orientated, speaking clearly, and was observed eating solids 
independently, this is information captured within the attending crew’s documentation. This 
is elaborated within the Patient Safety Incident Investigation (PSII) produced by York 
Teaching Hospitals where it states he was eating granola, not of soft consistency. This is 
verified in the paramedic’s statement that states “Both of us were unaware of the fact that 
the patient had a soft diet. Patient when we arrived was sat eating his lunch which had 
yogurt and what appeared to be granola. It was definitely not a soft diet item that he was 
eating”. Further to this, the PSII also describes how “Mr Brown had the capacity to make 
his own decisions.” It also states how “he is aware of the risk of choking but often chooses 
to ignore this and may need reminding. Colin also refuses thickeners in his drinks”.   

“In these circumstances, it is understandable how the crew did not identify a clinical 
indication to specifically escalate a choking risk as part of a non-pre-alerted conveyance. 
The documentation of previous swallowing difficulty within the medical history section of 
the ePR, and the verbal handover which included this detail, as per the paramedic’s 
statement, represents appropriate and accurate recording of historical background 
information for review by the receiving department. 

“Past medical history that is clinically active or presents an immediate risk would ordinarily 
be included within verbal handover. In this case, the patient’s Summary Care Record 
contained a pre-existing condition of difficulty in swallowing which was handed over both 
verbally and in writing. The patient did not indicate a requirement for a modified diet nor 
provided care plans to the crew. In these circumstances, the handover given by the crew 
appears appropriate and aligned to national guidance and human-factors principles. 

Delay between handover and ePR upload 

“YAS agrees that slight delays between verbal handover and ePR upload is inevitable 
given operational realities, including the need for crews to complete records safely 
following transfer of care and connectivity issues that can affect upload speeds. In this 
case, the subsequent choking event occurred approximately 90 minutes after ambulance 
handover and more than 50 minutes after the ePR was available to the receiving team, 
therefore placing it well beyond the period during which ePR upload delay would 
reasonably have influenced immediate clinical decision-making. In addition to the ePR, 

 
 
 
 
 
 
 
 
 hospitals also have access to several alternative patient care records where details 
indicating Mr Brown’s medical history and potential choking risk may have been available. 
One such example is the Yorkshire and Humber Care record.  

“At the time of ambulance assessment and on arrival in the Emergency Department, Mr 
Brown was alert, orientated, and able to speak in full sentences, with no recorded 
communication impairment, indicating that there was opportunity for relevant clinical 
history to be elicited as part of routine in-hospital assessment processes prior to decisions 
regarding oral intake. 

Verbal handover content and process 

“YAS clinicians use a structured verbal handover approach aligned to national best 
practice as described by AACE, RCEM and the Resuscitation Council United Kingdom 
(RCUK) that utilise an acronym to ensure consistency. This process prioritises pertinent 
clinical or background information relevant to the immediate presenting condition, 
physiological risk, and time-critical threats in a concise fashion. Pre-existing medical 
conditions such as dysphagia are pertinent and should be raised verbally as part of this 
process, but only where they are considered clinically active or present an immediate risk 
at the time of handover. 

“It is not feasible, nor clinically proportionate, for ambulance clinicians to identify and 
verbally communicate all potential secondary risks for every patient during every handover, 
particularly where these are longstanding conditions documented elsewhere and unrelated 
to the reason for conveyance. Adopting an approach such as this increases risk of key 
clinical information being missed and prolongs the handover process, meaning crews will 
be unable to respond to further emergencies. This is reflected in national guidance and 
contemporary literature advocating for structured, succinct handover. Structured handover 
therefore represents a balance between completeness and safety, aligned with human-
factors principles and the avoidance of information overload. 

“For non-pre-alerted arrivals, the receiving clinician’s signature on the ePR confirms 
acceptance of the verbal handover and formal transfer of clinical responsibility. 
Professional accountability requires that the written ambulance record reflects the content 
of the verbal handover provided at the point of transfer of care and does not materially 
deviate from it. 

“This principle mirrors standard Emergency Department practice, for example where a 
verbal referral is made to a specialty team and contemporaneous written documentation is 
expected to accurately reflect the content of that clinical conversation. The presence of 
additional contextual detail within the written record does not alter the substance of the 
verbal handover or introduce new clinical risks that were not identified as active at the time. 

“Accordingly, information documented within the ePR as historical medical background, but 
not escalated verbally as an active or immediate risk, should be interpreted as contextual 
record-keeping rather than evidence of omission from the handover process. 

 
 
 
 
 
 
 
 
 Swallowing risks 

”YAS notes that the assessment and management of swallowing safety and dietary 
suitability within the Emergency Department environment sits within the receiving 
organisation’s clinical governance and nursing assessment processes. Decisions relating 
to the provision of oral intake, including solid food, are made following arrival in hospital 
and are informed by local risk assessment, observation and, where indicated, swallowing 
screening or specialist review. These processes form part of a wider system of shared 
safeguards designed to manage risk across the urgent and emergency care pathway. 

“More broadly, national patient safety materials emphasise the risks associated with 
dysphagia and the need for clear, standardised approaches to food and fluid modification 
(including adoption of International Dysphagia Diet Standardisation Initiative (IDDSI)) 
terminology and avoidance of imprecise descriptors such as “soft diet”. These system 
safeguards sit most directly within in-hospital processes for assessing nutritional intake 
and swallowing safety.” 

Actions to be taken to prevent future deaths 

Notwithstanding the above, I accept that there is an opportunity to strengthen YAS and its 
partner’s practice on the communication of specific high-impact risks, such as swallowing 
or choking risk, where these are known and clinically relevant. 

The following actions have been agreed: 

1.  Clinical emphasis within handover guidance: YAS will issue a clinical alert to all 
staff to reinforce that known high-risk features not directly related to the presenting 
complaint (for example swallowing/choking risk, severe cognitive impairment, or 
behavioural risk) should be considered for explicit verbal handover where omission 
could reasonably result in harm and that clinicians document the contents of the 
verbal handover.  

2.  Review of handover protocols: YAS will review its handover protocols and update 
where appropriate to reflect contemporary practices and learning from this tragic 
case.   

3.  Targeted learning and awareness: Learning from this case will be incorporated 
into the monthly YAS Patient Safety Bulletin accessible to all clinical staff. These 
materials will also support local educational sessions (termed internally as 
‘investment days’) and will emphasise professional judgement, advocating for the 
continued use of structured, succinct and clinically pertinent handover 
conversations. 

4.  Electronic record development (subject to system constraints) 

YAS will explore, through its established digital governance processes, whether 
existing ePR systems can more rapidly share swallowing or choking risk in a 
consistent location, recognising that any such development is dependent on 

 
 
 
 
 
 
 
 
 capability, interoperability, and prioritisation alongside other patient safety 
requirements. This work has already begun, and YAS is exploring how pertinent 
clinical risks can be more accessible to receiving units.  

5.  System-wide learning 

YAS will share learning from this case through appropriate clinical forums and, 
where relevant, with system partners acknowledging that safe nutrition and 
swallowing management in Emergency Departments is a shared, multi-agency 
responsibility and aligned with national patient safety expectations regarding 
dysphagia and safe modification of food and drink.  

YAS does not propose to introduce a requirement for routine verbalisation of choking risk 
for all patients at every handover, as adopting such an approach would not be 
proportionate, operationally deliverable, or aligned with human-factors principles for safe 
handover practice or national guidance on succinct and timely handover practice. 
Requiring routine verbalisation of all potential secondary issues risks information overload 
by the recipient and increases the likelihood that clinically pertinent details are missed. 

Instead, YAS will reinforce through a targeted clinical alert that known high-impact risks, 
such as swallowing or choking risk, should be explicitly raised at handover where they are 
clinically active or present a foreseeable risk of harm. This approach supports professional 
judgement, maintains structured and succinct handover, and better prepares receiving 
teams without undermining the safety and reliability of the handover process. 

I support this response to the concerns identified, which proportionately balances patient 
safety, professional judgement, and operational reality. I consider these actions sufficient 
to mitigate the specific risk identified, while remaining aligned with national best practice, 
human-factors principles, and the shared responsibilities across the urgent and emergency 
care pathway, including robust hospital-based feeding and swallowing safeguards. 

My thoughts remain with Mr Brown’s family. 

Yours sincerely 

Chief Executive  

Cc. Senior Coroner for North Yorkshire and York