Andrew Roy KC and Charley Turton acted on a pro bono basis at the inquest into the death of Mr Eddie Cassin, a 66-year-old man with learning difficulties who died after being fed jelly by nurses at Milton Keynes University Hospital, despite having known dysphagia which put him at risk of aspiration.
Andrew and Charley were instructed by Caron Heyes of Fieldfisher who also acted pro bono on behalf of Mr Cassin’s family and in partnership with the learning disability charity, Mencap.
Caron recently spoke about the case, alongside Mr Cassin’s sisters, to ITV News. Watch the full ITV interview here.
The inquest heard from seven witnesses at a hearing at Milton Keynes Coroners Court in February 2025.
Assistant Coroner Dr Sean Cummings returned a narrative conclusion as follows:
Eddie Cassin was a delightful elderly male with learning difficulties who was prone to silent aspiration. Although cleared for discharge home he was developing an aspiration pneumonia on the 24th June 2023 which went unrecognised. He had hypoglycaemic episodes which were not managed according to trust guidelines. He was fed jelly which was expressly contraindicated. Food and medication was left in his mouth, some of which he aspirated. This was not recognised and exacerbated the already developing aspiration pneumonia. Had he been treated for the developing aspiration pneumonia he would likely not have died at the time he did. His death was contributed to by neglect.
The Assistant Coroner made a Regulation 28 report to prevent future deaths which he addressed to Milton Keynes University Hospital and Central North West London NHS Foundation Trust. In it, the Assistant Coroner said he was “disturbed” to discover that, 22 months after Mr Cassin’s death, there was still a lack of understanding of SALT and dietetic guidelines on managing patients prone to aspiration. The Trusts have until 12 August 2025 to respond.
