Jane Fenwick

Mr Hassan Shah 
HM Assistant Coroner for Northamptonshire 
The Guildhall,  
St Giles’ Square,  
Northampton  
NN1 1DE 

Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

1 April 2026 

Dear Hassan,  

Thank you for the Regulation 28 report of  19th February 2026, sent to the Department of 
Health and Social Care (DHSC), about the death of Mrs Jane Ann Fenwick. I am replying 
as the Minister with responsibility for adult social care.  

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Fenwick’s 
death; I offer my sincere condolences to her family and loved ones. The circumstances your 
report describes are concerning and I am grateful to you for bringing these matters to my 
attention.  

The Prevention of Future Deaths (PFD) report raises concerns over: 

1.  The  threshold  for  intervention  and  support  for  individuals  such  as  Mrs  Fenwick,  who 
despite having a number of interconnected concerns about eating which could lead to 
choking, nevertheless was not referred to Speech and Language Therapy (SALT). 

2.  Current waiting lists for individuals such as Mrs Fenwick to be referred to SALT. 

In preparing this response to your first concern, departmental officials have made enquiries 
with Care Quality Commission (CQC) and North Northamptonshire Council (NNC) and Chair 
of  the  Northamptonshire  Safeguarding  Adults  Board  (NSAB).    Officials  did  this  to  gain  a 
greater insight into any specific reasons for Mrs Fenwick not being referred to SALT and 
what, if any, follow up actions may have resulted from this case.  However, with regards to 
the  second  concern,  then  NHS  England,  who  also  received  a  copy  of  this  report,  will  be 
reporting separately on current waiting lists for SALT. 

Any form of neglect is unacceptable, and my department recognises the importance of safe, 
person-centred  care,  particularly  in  relation  to  eating  and  drinking.  This  is  why  the  Adult 
Social  Care  Learning  and  Development  Support  Scheme  (LDSS),  was  launched  in 
September  2024,  and  provides  funding  for  eligible  care  staff  to  undertake  courses  and 
qualifications,  including  a  Level  2  Certificate  in  Understanding  Nutrition  and  Health  and 
relevant content in the Level 2 Adult Social Care Certificate (L2ASCC).   

 
 
 
 
 
 
 
 
 
 
 
 
     
  
 
  
  
 The  L2ASCC  gives  care  workers  the  baseline  competence  to  prevent  and  respond  to 
choking. It includes nutrition and hydration training, how to identify and report related risks 
or changes, how to support individuals in line with their needs and care plans, and how to 
respond appropriately in emergencies, such as choking. 

My officials have spoken to CQC, who have an open case concerning this incident, which 
was referred to the CQC's Specific Incident Progression Team in November 2025, for an 
initial  fact-finding  stage.  The  outcome  of  this  fact-finding  will  determine  whether  CQC 
proceed with an investigation. 

CQC note that risks associated with eating were not consistently addressed in practice and 
supervision  did  not  occur  on  the  day  of  the  incident,  although  the  care  plan  stated  Mrs 
Fenwick should be observed while eating, as it identified a risk of choking.  

Although no referral was made to SALT, local SALT advice to CQC indicated that although 
a full assessment might not have progressed, general guidance could have been provided 
had a referral been made. However, due to this case being ongoing, CQC cannot provide 
any further detail at this stage. 

My  officials  also  spoke  to  NNC  and  the  NSAB  Chair,  and  they  confirmed  with 
Northamptonshire Healthcare Foundation Trust (NHFT) Specialist Community Services that 
community referrals are triaged by SALT and the information provided is used to identify the 
referral  as  routine  (within  13  weeks)  or  high  priority  (within  4  weeks).  Once  triage  is 
completed  the  care  homes  are  often  given  information  and  advised  to  trial  alternative 
consistencies  if appropriate, until they  are able  to  visit.   If a  referral has  been made  with 
choking as a risk identified, it would however have been triaged as high priority.  

Following inspection of documentation that my officials received from the NNC, including a 
timeline  and  care  plan  for  Mrs  Fenwick,  as  well  as  the  additional  information  referenced 
above from NHFT, my officials have provided CQC with this additional information, to aid 
their fact-finding stage.  

Separately NNC have indicated that in their view, although this was a tragic incident, it is 
being viewed as an isolated incident, as  it has been determined that there are no similar 
risks to other people in the service or identified failings to warrant a Safeguarding Adults 
Review  Referral  under  section  44  of  the  Care  Act.  However,  the  NNC  will  be  engaging, 
alongside the NSAB, with the coroner and if any additional information becomes available, 
then NNC will consider this and any associated learning. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely, 

MINISTER OF STATE FOR CARE

Mr Hassan Shah 
Assistant Coroner for Northamptonshire 
The Guildhall 
St Giles’ Square 
Northampton 
NN1 1DE 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

6th May 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Mrs Jane Ann Fenwick 
who died on 21 August 2025. 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19th 
February 2026 concerning the death of Mrs Jane Ann Fenwick on21 August 2025. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Mrs Fenwick’s family and loved ones. NHS England 
is keen to assure the family and yourself that the concerns raised about Mrs Fenwick’s 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any  anguish  this  delay  may  have  caused  to  Jane’s  family  or  friends.  I  realise  that 
responses to Coroners’ Reports can form part of the important process of family and 
friends coming to terms with what has happened to their loved ones, and I appreciate 
this will have been an incredibly difficult time for them. 

Your Report raises concerns regarding the threshold for intervention and support from 
Speech and Language Therapy (SALT) Teams and the current length of their waiting 
lists for patients to be seen. 

NHS England was not a party to the inquest, and we have therefore not had sight of 
or  heard  the  full  extent  of  the  witness  evidence  relating  to  the  issues  raised  within 
Sections 3 and 4 of your Report. It is, therefore, difficult to answer the concerns without 
knowledge of who developed Mrs Fenwick's care plan, whether the care plan included 
SALT input and under what circumstances it was written. Whilst the risk of choking 
was identified in the care plan, its not clear if any mitigations had been included in the 
plan. It isn't clear whether this was discussed with a local service and rejected or the 
care home made an assumption about referrals.  

The referral criteria for SALT is agreed locally, aligned to commissioning and service 
models but referral decisions should be based on an individual's need. Not having a 
previous choking episode should not prevent a referral if the wider clinical history and 
risk of choking are recognised and included in the referral. 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 Regional Response 

SALT referral criteria is agreed locally, aligned to commissioning and service models. 
However, referral decisions should be based on an individual’s need. The absence of 
a previous choking episode should not prevent a referral if the patient’s wider clinical 
history and risk of choking are recognised and included in the referral.  

NHS  England  does  not  routinely  disaggregate  AHP  vacancy  data  by  each  of  the 
constituent professionals (e.g. SALT), or area of practise (e.g. community services) or 
by specialisms (e.g. adult care). The Royal College of Speech and Language Therapy 
reports SALT NHS Vacancy rate of 13% (based on a survey with 215 employers).  

The Community Health Services SitRep reports that in the latest data (January 2026):  

•  26,796  adult  waits  are  reported  for  speech  and  language  therapy.  Of  these 
9552 (35.7%) have waited over 12 weeks, 5,929 (22.2%) over 18 weeks, and 
343 (1.3%) over a year.  

•  65,540 children and young people waits are reported for speech and language 
therapy. Of these 31,059 (47.4%) have waited over 12 weeks. 21,173 (32.3%) 
over 18 weeks and 4,942 (7.5%) over a year.  

Community health services speech and language therapy services assess, diagnose 
and treat adults and children and young people with communication and swallowing 
disorders.  

The  Medium-Term  Planning  Framework  states  that  in  2026/27,  Integrated  Care 
Boards are required to:  

• 

Increase  community  health  service  capacity  to  meet  growth  in  demand, 
expected to be approximately 3% nationally per year.  

•  Actively  manage  long  waits  for  community  health  services,  reducing  the 
proportion of waits over 18 weeks and developing  a plan to eliminate all 52-
week waits.  
Identify  and  act  on  productivity  opportunities,  including  ensuring  teams  have 
the digital tools and equipment they need to connect remotely to health systems 
and patients, and expanding point of care testing in the community.  

• 

•  Continue  to  standardise  core  service  provision  as  defined  in  Standardising 

Community Health Services.  

•  Consider where digital therapeutics, such as musculoskeletal treatment, could 
be  deployed  at  pace  where  those  therapeutics  have  appropriate  regulatory 
approval.  

There requirements are expected to drive uplift in community health service activity, 
by  expanding  capacity,  improving  productivity,  and  enabling  teams  to  deliver  care 
more  efficiently  and  locally  –  whilst  targets  are  not  service-line  specific,  this  should 
impact positively on speech and language therapy services.  

The  recently  published  NHS  England  »  Community  health  services  waiting  times: 
actions  to  meet  Medium  term  planning  framework  targets  guidance  outlines 
recommended  actions  to  support  achievement  of  the  Medium-Term  Planning 

 Framework  waiting  time  targets.  It  is  supported  by  an  annex,  Community  health 
services  waiting  times  action  lists,  which  describe  both  ‘core’  and  ‘going  further’ 
activities to be considered alongside existing 2026/27 ICB and provider plans.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking place around the Reports to Prevent Future Deaths. All reports received are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Mrs 
Fenwick, are shared across the NHS at both a national and regional level and helps 
us to pay close attention to any emerging trends that may require further review and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

Yours sincerely,   

National Medical Director  
NHS England