“(brief summary of matters of concern) The Speech and Language Therapists (SALT) and…”
Dated 18 Jun 2025, from the coroner for Milton Keynes. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
All responses publishedReplies were due by 13 Aug 2025.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk; a reply may have been sent and not yet published.
- Report dated18 Jun 2025
- Deadline13 Aug 2025
- Published on judiciary.uk14 Jul 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Milton Keynes University Hospital NHS Foundation TrustNamed in the report as “Milton Keynes University Hospital” | Response publishedPublished on judiciary.uk in July 2025. |
| Central and North West London NHS Foundation TrustNamed in the report as “Central North West London NHS Foundation Trust” | Response publishedPublished on judiciary.uk in July 2025. |
The coroner’s concerns
(brief summary of matters of concern) The Speech and Language Therapists (SALT) and Dietetic Service had well developed, comprehensive guidelines for investigating and managing patients prone to aspiration. Those guidelines were disseminated through the wards at Milton Keynes University Hospital and nursing and other staff were appraised of them or at least, should have been. I was disturbed to discover though that there was a lack of understanding of some of those policies and procedures some 22 months or so after the death. The SALT and Dietetic services are provided by the Central and North West London NHS Trust into the Milton Keynes University Hospital NHS Foundation Trust. It appeared to me that both Trusts were 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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0315
- Added to Minute Book
- 8 Oct 2026
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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