Day 1 of David’s inquest took place today, Thursday 7 November, in Hull Coroner’s Court, with Assistant Coroner Edward Steele presiding.

There are two sets of Interested Persons. David’s family are represented by Ciara Bartlam from Garden Court North, instructed by Dawn Makepeace of Watson Woodhouse Solicitors. Hull University Teaching Hospitals NHS Trust are represented by Sarah Lyle of Capsticks LLP instructed by Shaun Lancaster at the Trust.

The coroner starts by introducing himself and offering his condolences to David’s family, before checking with their counsel how they would like to be referred to, it’s decided on David not Mr Lodge, and Keri not Dr Lodge.

The coroner also wishes to place on record his apologies to the family that it has taken so long to get to court. David turned 40 a month before he died, on 13 January 2022. The inquest into his death was opened and adjourned a week later, on 20 January 2022.

The coroner said many letters and directions had been issued in this case, that it was not an Article 2 case although he would keep that under review. He told the court that the scope had been reviewed and was set as answering the four main questions of who David was, when he died, where he died and how he died. The coroner said he would be considering the medical treatment provided by Hull Royal Infirmary on 12 and 13 January 2022.

Roughly half an hour discussion about housekeeping followed including discussions about witnesses. It was agreed a tranche of witness statements relating to social care support to David would not be read in court as social care support had been ruled out of scope, but the coroner would receive them into the evidence of the inquest.

The coroner wished to raise a point about impartiality and respect for the family. He flagged that some of the earlier communications “were not so blissful as my usual practices as a coroner are” but he wished the family to feel “completely respected by everything I’m doing”. He explained that impartiality must trump everything, but he wanted to explain that and set the tone right at the beginning of the hearing. Ciara Bartlam acknowledged that was recognised by the family.

The coroner said that he was grateful for Keri’s statement, which he said informed many things, not least the appointing of experts in the case. He said some of Keri’s statement “spoke to a number of issues outside my determination in respect of scope”. He explained he meant no discourtesy, but consequently it would not all be read onto the record.

He then outlined which paragraphs he proposed to have read in court. Counsel for the family agreed that his suggestion was not controversial, however she raised that there were press present who may wish to read the family statement in full and sought permission to share it with me. The coroner had no issue with that.

Ciara Bartlam then raised three additional paragraphs that she wished to have admitted from Keri’s statement, and that was agreed with the coroner and Ms Lyle.

There was some discussion about Prevention of Future Death reports and the coroner put the Trust on notice that he was concerned about the potential delayed transfer of David to the ward, given the expert’s evidence. He then added that all the clinicians were experts, and he meant no disrespect to anyone present in court, but he was referring to the impartial experts.

Ms Bartlam said that she would be putting her submissions on Prevention of Future Deaths into writing for the coroner. He said he would appreciate that, but as counsel in his day job, he understands the demands on the legal teams so he would not be making a direction for them to do that. Ms Lyle said that she would make oral submissions.

A discussion then followed about a statement offered by a Dr Hibbert at the Trust. Ms Lyle wished the coroner to know that Dr Hibbert was available tomorrow if required. The coroner said that he had acquiesced to the view of the family, his preliminary view had changed and he did not intend to call Dr Hibbert, but depending on how the evidence “pans out” he could see “a potential benefit maybe”.

The coroner summed his position up as “the mischief is what is the value of the evidence? We have the people who gave the treatment”. He said he believed the points were already covered, that there was good evidence from the treating clinicians and the experts’ evidence. He told Ms Lyle that her predecessor had authorised the direction of the appointment of independent experts.

“Therefore, what is the value, without being disrespectful, in respect of Dr Hibbert’s evidence… do you follow my logic there?”

The discussion continued for some time before the coroner confirming that he would see how the evidence developed, before making a final decision.

The coroner then said he needed to make a few legal explanations to place them on the record. He acknowledged all the advocates knew what he was to say, but he highlighted that an inquest is an inquisitorial not adversarial process and that everyone was to assist him as coroner to make best decisions on causation and medical cause of death. He explained he asks questions for the purposes of answering his statutory responsibilities. He also explained that evidence is judged against the civil standard of proof, something is more likely than not.

He provided some further introduction and then the first evidence was from the pathologist.