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

6th May 2026

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,

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.