Following the mid-morning break, the Coroner’s Officer returned to the witness stand to continue reading evidence onto the record.

She read the statement of Dr Jorge Milazzo of Newland Health Centre.

He told the court that David had been registered at their practice since 1982.

“I became his main General Practitioner in 2018 and when I initially met David, he was wheelchair bound and presented with challenging behaviour.

In his medical notes he has several health issues including Autistic Spectrum Disorder, Speech, Language and Developmental Disorder, Physical and Mental Retardation, Learning Difficulties, Right Cataract, Blindness due to Retinal Detachment, Chronic Constipation and Difficulty Swallowing / Dysphagia”.

He went on to describe David’s allergies and his interactions with other services.

The last time he had seen David face to face was on 7 August 2020. He told the court David had been seen by others since then and there were clear communications with agencies.

“David was admitted to hospital in July 2021 under the care of the Oral and Maxillofacial service to have an examination under anaesthesia of his oral cavity, tracheostomy scar, eyes (via ophthalmology), ears and dental clearance, and was treated for these issues under a Court Protection Order.

During his last year of life, he was practically bed bound”.