Mr Cummings said his diabetes had been difficult to manage and there were several alterations to his insulin regime.

On the 24 June 2023, he had a hypoglycaemic episode requiring treatment and the hospital guidelines were not followed.

Because of his dysphagia he was on a modified diet and required supervision when eating to mitigate the risk of choking.

Despite this, there was evidence he was repeatedly fed jelly – highlighted as a food he should not be given – through his stay including on the 24 June.

He was not properly supervised and he aspirated.

Caron Heyes, a director at Fieldfisher representing Mr Cassin’s family, said: “We were shocked that eight years after Public Health England issued clear guidelines about the dangers of feeding inpatients with dysphagia and learning disability, they are still not recognised in a major hospital.”

A spokesperson for Milton Keynes University Hospital NHS Foundation Trust said: “We are profoundly sorry for the failings in Mr Cassin’s care. We fully acknowledge the deep distress experienced by Mr Cassin’s family and would seek to assure them that we have taken careful steps to understand what happened, including commissioning an independent external review.

“We will respond to His Majesty’s Coroner’s Prevention of Future Deaths notice in full.”