David Lodge, a 40-year-old man with a learning disability and autism, died on 13 January 2022 at Hull Royal Infirmary.

David was born and raised in Hull and was one of three children. He lived at home with his father, Peter, and really enjoyed spending time with his mother, sister, brother and wider family. David was very much loved and is very much missed by his family.

David was born with a learning disability, dysarthria (which meant he could not speak using words) and dyspraxia. He became registered blind in adulthood, and was subsequently diagnosed with autism. Following a prolonged period in intensive care with pneumonia following dental treatment in 2017, David lost the ability to stand or walk and became a wheelchair user.

Prior to being hospitalised in 2017, David enjoyed a variety of hobbies including swimming, shopping for DVDs, watching films at home with Peter, visiting his nieces, and going to the cinema.

At the time of his death, David had been living at home in the sole care of his father, Peter, since July 2021.

Tragically, on 12 January 2022, David’s sister Keri found David at home lying on the floor next to the body of their father who had unexpectedly died up to 4 days earlier. David was physically weak but alive when he was found and was taken to Hull Royal Infirmary (‘HRI’) where he died from severe pneumonia the next day.

David’s inquest considered the care and treatment he received on 12-13 January 2022 at HRI; and, in particular, whether there was anything more that could have been done to escalate David’s care and whether he was treated differently because of his disabilities.

The Court heard evidence that David had been admitted to HRI at around 4.30pm on 12 January 2022. He had been triaged by a nurse at 5.19pm and a consultant in emergency medicine attended to see him 2 minutes later. Given that David had been lying next to his father for up to 4 days, it was readily apparent that he would need fluids and rewarming. The consultant also knew that David had a history of aspiration pneumonia and other risk factors.

Although the consultant did not witness any agitation himself, he was aware that David had been described as being agitated earlier that evening and that he had always been very distressed by anything medical to the extent that he was not able to tolerate going to see his GP and required reasonable adjustments. Due to this, the consultant decided that David would need to be sedated before a full examination could take place and fluids administered. Although David had a hospital passport, the consultant did not know this at the time and did not ask to see it.

David was administered with 10mg midazolam at 6.25pm which was expected to have taken effect around an hour later, but nothing further was done until shortly before 9pm when David’s physical observations were taken showing a NEWS score of 9 (in the emergency category). The consultant attended to take bloods and administer fluids but did not complete a chest examination using a stethoscope and did not touch David again after this point.

David remained in the Emergency Department until around 1am on 13 January 2022 when he was transferred to the Acute Admissions Unit (‘AAU’). During that time, David’s physical observations were taken at 9.37pm, 10.29pm, and 11.07pm producing a consistent NEWS score of 9. David’s observations were taken for a final time in the ED at 12.48am and produced a result of 8 indicating that David’s condition was still extremely serious and that a referral to critical care ought to be considered. Instead, David was administered further sedative medication (lorazepam) while his sister was out of the room and transferred to the AAU without the knowledge of the on call registrar.

While at AAU, David was seen once by a nurse shortly after admission. Because his physical observations seemed to improve, David was not seen again until he went into cardiac arrest at 2.49am. An end of life care plan was agreed and David died later that morning.

During David’s inquest, the Court heard evidence from David’s sister and key decision makers, such as the consultant in charge of David’s care in the Emergency Department and the (then) registrar from the Acute Admissions Unit. The Coroner also heard evidence from an expert in emergency medicine (Dr Athey), instructed by David’s family, and its own independent critical care expert (Dr Breen). During the final inquest hearing, the doctor from the AAU admitted a number of failings, including that there were two missed opportunities for David’s observations to be taken between 11.07pm and 12.48am and that a referral to critical care and admission to the Intensive Care Unit would have prevented David’s cardiac arrest on the balance of probabilities. The AAU doctor also told the Court that she was not aware of the administration of lorazepam and, if she had known, she would have put a halt on the transfer to AAU. In her opinion, the administration of lorazepam more than minimally contributed to David’s cardiac arrest.

In Dr Athey’s opinion, the decision on whether to escalate David’s treatment should have been discussed with his family and the omission represented substandard care. He described the failure to refer David to ICU as the ‘single most significant omission that may have altered [David’s] outcome’. He told the Court that, in his view, the top two working diagnoses focussed on David’s social and behavioural issues rather than the acute medical issues. Dr Athey said he did not believe that this would have been the case had the patient being assessed been a 40 year old without a history of learning difficulties, dysarthria, dyspraxia and autism.

On causation, it was apparent from David’s condition that he was sadly unlikely to have survived to discharge. However, in Dr Breen’s opinion David’s life would have been more than minimally prolonged ‘by days’ if he had been admitted to ICU. He told the Court that David should have been considered for ICU transfer before midnight on 12 January 2022 and that, even in his physically weakened state, it would have been reasonable for David to have been admitted to ICU.

The Coroner concluded that David’s death from natural causes was contributed to by neglect. In reaching that conclusion, HMAC Steele made 10 key findings including missed opportunities:

1. That an examination of David’s condition, including physical observations should have occurred at around 7.25pm and that an examination at around 8.53pm ‘was too late’.
2. That a thorough chest examination was not undertaken at any point and should have been undertaken ‘if not at then before 9pm’.
3. That there were 2 missed opportunities to take physical observations between 11.07pm and 12.48am.
4. That David’s fluid treatment was ‘insufficiently monitored’.
5. That David should have been properly considered for (if not admitted to) the Intensive Care Unit.
6. That David should have been admitted to the Intensive Care Unit and that that should have happened before midnight. The Coroner found that it ‘was not speculation to say that by that point David was failing to respond to treatment’.
7. That David’s condition was not appropriately monitored following the administration of lorazepam.
8. That, had David been admitted to the Intensive Care Unit, with the benefit of continuous monitoring and reduced nurse to patient ratios, he would not have suffered a cardiac arrest.
9. That (1) David would have survived if he had been able to summon help soon after his father died; (2) David was unlikely to survive to discharge once he had he been found and taken to hospital; (3) there was a point in time where David’s ability to summon help may not have made a difference and which is impossible to determine.
10. Adopting the opinion of Dr Breen, that David’s life would have been prolonged ‘by days’ if he had been admitted to ICU.

The Coroner did not make a finding on anything that pre-dated David’s admission to hospital on 12 January 2022; including whether there were any failings that may have contributed to David’s inability to summon help.

At the end of the hearing, the Coroner said he would be making a prevention of future deaths report addressed to the Trust on 4 bases:

1. A concern that pain is not being accurately assessed in people who are unable to communicate using words.
2. A concern that basic examinations are not being carried out for learning disabled adults at risk of pneumonia in the Emergency Department.
3. A concern that NEWS2 scores above 7 are not appropriately escalated.
4. A concern that opportunities for learning from serious incidents are being lost.

Dawn Makepeace Solicitor at Watson Woodhouse Law Firm, representing the family said: “David died in the most tragic of circumstances. The inquest has heard of the failure by the Trust to provide adequate treatment. His death may well have been avoided if it wasn’t for the failings and multiple missed opportunities by multiple agencies of the state. It is unimaginable what David went through in those final days, laid next to his father’s body, unable to help. Keri and Christopher lost their brother, as well as their father. They hope that lessons have been learned so that no other family have to go through the pain and loss they have endured.

David’s family stated “David overcame a lifetime of challenges, not least the attitudes of professionals in health and social care who did not understand that, just because a person cannot speak words, it doesn’t mean they can’t think and feel. David was the bravest brother, son and uncle, but what he endured in his final days is unimaginable. The inquest’s findings that the care provided to David was so substandard was shocking. David was a person, first and foremost, but that was forgotten by those treating him. Whilst I am grateful that the inquest has resulted in four prevention of future deaths reports being issued to Hull Teaching Hospitals NHS Foundation Trust to address some of the ways in which Hull Royal Infirmary failed him once he got to hospital, no lessons have been learned about ensuring adults and children who live at home with a sole carer, such as an older parent, have a way to get help in an emergency. David deserved better, and we must make sure that nobody else goes through what he did in his last days. David is missed beyond measure.”