Edward Cassin
18 Jun 2025 · Coroner Sean Cummings · Milton Keynes
The coroner's concerns
1. lack of understanding of policies and procedures
“The Speech and Language Therapists (SALT) and Dietetic Service had well developed, comprehensive guidelines for investigating and managing patients prone to aspiration”
2. siloed manner
“both Trusts were working to a degree in a siloed manner”