The coroner said that next we would move onto the two statements made by David’s sister, Keri. His coroner’s officer read them onto the record.

The first statement was a short identification statement that said:

On the 12th January 2022 David was admitted to Hull Royal Infirmary, Anlaby Road, Kingston Upon Hull. I was with him at the time until, he subsequently died on the 13^th January 2022.

I can confirm that the person who passed away was David Lodge my brother and that I have seen him after death.

Keri’s second statement was much more detailed. Some of it overlapped with the profile I wrote about David having spoken with Keri, which you can read here.

Keri told the court that David was born in December 1981, the second child to her parents, Juliet and Peter. Her mother is a retired Professor of Politics and her father was a stay at home Dad and later a full-time carer for David, until his death.

David had always lived at their family home with their father. He was a middle child, Keri is his elder sister and their younger brother, Christopher, lives in Canada. When their parents divorced in the early 90s David and Keri continued to live with Peter.

“At the time of his death, David was 40 years old and was not in education or employment. David had a number of health conditions and disabilities from birth, including autism, a learning disability, dysarthria (which meant he could not speak using words, but he was proficient at typing what he wanted to say on his Lightwriter electronic communication aid), dyspraxia, visual impairment and immobility, which are detailed further below.

David was living at home in the full-time care of our father, Peter, who was 74 years old and fit and well as far as we knew until his unexpected death.

Respite care was slowly being introduced, overseen by the Court of Protection following a section 21A challenge to David being deprived of his liberty at Pennine Resource Centre (Hull) where he was taken for respite for 28 hours twice a week until this stopped in February 2020″.

Keri told the court that David enjoyed going swimming, going to the cinema, going shopping for DVDs and visiting his mother for short visits, and visiting Keri in York.

She said David had been diagnosed with autism in adulthood, following a change in his behaviour after being registered blind, and experiencing post operative complications. She said that David’s behaviour in adulthood, was different to his behaviour in childhood.

“In childhood, he was able to cope with changes to his routine, and had less need for sameness and predictability in day-to-day life. However, in adulthood, a key way in which autism was manifest in David was in his need for sameness and predictability.

David found life easier to manage if he was able to maintain his routines, for example, he would only use specific plates at home; food had to be presented in a particular way; and he would only wear particular types and colours of clothing. David experienced significant distress at even small changes in his routine.

Peter had an in depth understanding of David’s need for routine and predictability”.

Keri told the court about some of David’s sensory needs and experiences, adding that despite them being described in a sensory assessment report by an occupational therapist from the Community Learning Disability Team “they were not always acknowledged by his social worker and other professionals who were involved in making decisions about David’s social care arrangements”.

Keri explained that in the months before David died he was allocated a new psychologist within the CLDT, Dr Alex Hamlin, who agreed a formulation was important to plan for David’s care arrangements, and also agreed a trauma informed approach was needed.

The formulation meeting was arranged for two weeks after David died, on 27 January 2022.

Keri outlined what other support was available from Dr Hamlin, from a learning disability nurse, a physiotherapist and an occupational therapist in the CLDT. She told the court David had support from a speech and language therapist in the past but was not under their care when he died.

“David had a social worker, Paddy McIntyre, from the Hull Community Learning Disability Team. Paddy had not seen David in the months before he died, and I had suggested that the best way to do this would be in a place he felt comfortable, but this suggestion had not been followed up by the time David died.

This contrasted to the approach of the independent social worker who had spent time with David when compiling a report on his views on meeting David’s social care needs as part of the section 21A challenge Court of Protection proceedings, and the independent psychiatrist, who had also spent time with David in 2021 when preparing a report for the Court of Protection on her views regarding the proposals for his covert dental clearance.

David had also been allocated a mental capacity advocate, however she had not met him before he died. She had, however, made telephone enquiries about David’s recovery from his dental surgery and we had planned that, once David could tolerate it, she would meet him in a place he felt comfortable to try to begin to establish a relationship with him”.

Keri then told the court about David’s Social Circumstances, outlining the arrangements for David’s care overseen by the Court of Protection. The Court of Protection had decided that it was in David’s best interests to continue to reside in his own home, receiving care there from Peter as his principal carer, with support from Keri, with a plan to support David to become familiar with staff from Wasdale Court, Hull, with a view to respite in the longer term.

Her statement then moved on to talk about David’s Educational History. She described an inclusive mainstream nursery and primary school, St Nicholas Primary School in Hull. David had a Statement of Special Educational Needs and a teaching assistant to provide 1:1 support.

Everyone at the school, all the pupils and all the staff, learnt Makaton so David had a means of communicating with those around him, and it enabled him to be included in everyday school life.

“I cannot remember a time when I did not feel protective towards David and aware of my responsibility to stand up for him.

David had some friends at primary school, including a best friend who is now a teacher specialising in special educational needs. He also took part in all school events, such as nativities, plays, sports days and the residential school trip.

I think these were his happiest days, and I think this is because he was included, people knew how to communicate with him and he was able to be understood”.

Keri went on to describe David’s time at Secondary School and College where he was on a life skills course. She outlined bullying that David experienced from his peers, and he also told his family of a member of staff twisting his arm. He eventually refused to get ready to go to college.

Keri mentioned the summer playscheme David attended by an organisation called Kids. It was for young adults with special needs in Hull and David really enjoyed that, doing a range of activities such as canoeing and swimming.

Keri’s statement told the court about David’s medical background. She was not aware of any hereditary medical conditions, but she listed a number of medical conditions and diagnoses David had at the time of his death, including a mild/moderate learning disability, autism, dysarthria and dyspraxia.

David had developed aspiration pneumonia following dental treatment under sedation in 2017. This had required an admission to Intensive Care.

The coroner’s officer continued with Keri’s statement, in relation to the circumstances of David’s death. She said in the weeks leading up to David’s death there were no acute or new medical concerns about him. She said her father had suffered from indigestion over the Christmas period, but she believed those symptoms had resolved in a few days. She had no concerns about her father or her brother.

“Peter appeared fit and well, his indigestion symptoms had resolved, and he was as committed as ever to caring for David. He would frequently comment on how settled David was and what a pleasure it was to see David smiling and having a joke with him.

He also commented on how nice it was to hear David making vocalisations indicating that he was content when he was using YouTube as he hadn’t heard David make these sounds for many years. He would also talk with me about how it was good to see David able to concentrate on reading again, as he had not been able to do this since 2017”.

Keri had last seen David on Wednesday 5 January 2022. He had used the Makaton sign for shopping for the first time since the previous July. Keri spoke to David about whether he wanted to go shopping then (he didn’t) but he was considering it for the following week. She told the court that she felt positive David was thinking about going to the shops again, and that he was mulling over the idea.

“When I said I will see you on Wednesday then, he smiled, ruffled my hair, blew another raspberry and then waved at me, which again, was usual for him. I left the house sometime between 7.30 and 7.40pm on 5 January 2022 with no concerns and feeling positive about the next time I would see him.

When I last saw Peter on the above date, there were no acute health concerns. He went shopping as usual, did some gardening, and we ate a meal together and had a chat. On leaving, as usual, I asked Peter if he wanted me to come back at the weekend to look after David whilst he had another rest, and he said he did not want me to do this as they were both in a good routine and fine.

As usual, I told him that if he changed his mind, I could come anytime, including overnight over the weekend. As usual, I also told him I would ring him to see how he was doing, and that I would be back on Wednesday if not before. Peter said, “See you on Wednesday”. I left with no concerns and feeling positive that 2022 was getting off to a good start for David and would be a year for moving forwards for them both”.

Keri said she could not recall exactly when she last spoke to Peter as she rang Peter and David every day, sometimes more than once a day. She described their weekly routine to the court, and how on occasion Peter would not be able to take a call as he was providing support to David.

She described how on the morning of Wednesday 12 January she called her father to check if there was anything they needed from the shops, in addition to the usual shopping she would take them. She got no reply.

She described driving to her family home, waiting outside, thinking her father and David must be busy. She then described how she waited for longer thinking that they must be sleeping when they did not respond to her phonecalls or shouting through the letterbox. She realised the latch was down inside so her key to the door would not work. She outlined her thought process, discussing what to do with her partner and messaging with her brother.

Growing increasingly concerned she contacted a Hull locksmith, anticipating her father would be woken by his attempts to get into the house and tell her off for calling a locksmith. The locksmith came quickly and stayed while Keri went into the house. She described to the court the scene she found, her father lying on the floor, and David lying near to him, their feet touching.

“I recall thinking-why are they both having a nap on the floor? As I was aware of Peter being on the floor next to him, and that they were lying facing each other with their feet touching”.

She said she thought she heard David breathing, but as her eyes scanned and she saw her father’s face she realised that he was dead. Keri rushed out of the room to call 999, crouching down to do so as she felt she couldn’t stand.

She said the emergency services seemed to arrive quickly and she waited in the porch whilst the paramedics went into the living room. She said it was not a surprise when one came out to confirm Peter was dead.

“They also told me David was alive, and I recall saying, “thank you, thank you” as I was relieved that he was alive. The paramedics told me they needed my help to get David into the ambulance. I recall them saying they would cover my dad’s face before I went back into the room. I recall following them back into the living room, stepping over my father’s body which was now covered by the bed sheet which I think must have been taken off David’s bed by the paramedics.

I went over to David and saw that he was awake but very weak. I cradled David and said to him “You poor fella, have you been on the floor for ages?”, to which he nodded (poor fella/poorly fella was the term he used to refer to himself when he was feeling rough or unwell).

I tried to reassure him that it was ok and that we were going to help him. I recall David was very weak, he was not screaming or hitting out at himself or the staff, which is how he would usually respond in these circumstances, and pointing this out to the paramedics.

I recall trying to reassure him that we were going to get him sorted. I recall asking him if it was hurting anywhere, but he didn’t respond to this. I recall getting David some clothes and helping him put them on. I recall he shook his head about this at first, but I explained he was cold, and he needed his clothes on to warm up.

Usually, if David did not want to put his clothes on, he would actively resist this, but he did not resist at all, and again, this struck me as an indicator that he was really weak, and I pointed this out to the paramedic”.

Keri explained her concerns that David might have a head injury to the paramedics, as his pupil looked strange and he had a bruise on the side of his head. She didn’t know how David had got from his bed, which was still raised, to the floor and she was worried he may have hit his head or fallen.

Keri described that David wanted his shoes and coat on in the ambulance and that he signed the Makaton sign for home. Keri reassured David that they’d get him sorted and come home after.

“He seemed very tired and weak, and he did not hit himself or me in the way that he usually would when in an ambulance. I cannot recall which observations the paramedics were able to complete during the journey to the Emergency Department at Hull Royal Infirmary.

I recall that on arrival at the Emergency Department at Hull Royal Infirmary, David was put into a cubicle. I sat next to him. I offered him a drink of Lucozade, but he shook his head. He indicated that he wanted covers on, so I tucked him in and he lay on his side resting against me. I recall saying, “You have a rest, you’ve had a tough time, but you’re ok now.”

I felt it likely that David was dehydrated, and I hoped this would be assessed quickly so that he could have intravenous fluids if needed. I recall wondering if his blood sugar might be low and I recall wondering if he had a head injury.

A nurse eventually came in and when I spoke with her, she said she did not want to do too much as she did not want to upset him. I remember saying that he was weak and saying that it must be days since he had anything to eat or drink. I recall the nurse saying he would be reviewed by a doctor soon. I do recall the nurse asking me if David had had Covid and doing a nasal swab, which did not distress him, and that I commented on how unusual this was”.

Keri told the court that “it felt like a long time” before they were transferred to a room in the Emergency Department. She recalled speaking to the ED Consultant and explaining a bit about David’s background. He told Keri he was aware David had been in hospital in ICU previously.

She said that she had explained the circumstances of David’s admission and her concerns about David potentially having a head injury as he was bruised and his pupil looked unusual.

“I recall the consultant saying that if David had had an extradural haematoma, he would have died of it by now. I recall asking whether David would have a head scan, but he explained he did not think this was necessary right now and that I could ask the medics about on the ward.

The consultant gave David some sedative medication before doing some blood tests. I recall the consultant explaining that David’s blood test results were not as bad as they could be, and that he was dehydrated and would be given some IV fluids and admitted to the Acute Assessment Unit”.

Keri told the court that the consultant had said David was also cold and being rewarmed. She said she felt relieved when the consultant said with fluids and rewarming overnight, the medics would speak to her in the morning about planning David’s discharge.

“I recall feeling so pleased that David was going to be ok, and making arrangements to enable me to remain with him overnight.

I sat by David’s bed whilst he appeared to sleep in his room in the Emergency Department, and I contacted Christopher and Juliet to explain what had happened”.

Keri continued with her recollections of David’s time in the Emergency Department. She asked that David be given some paracetamol as he usually had it for sacral pressure area pain, but by the time David left the department to her knowledge he had not been given any pain relief.

“Whilst David was in the Emergency Department, I recall his temperature being monitored. I recall his blood pressure being monitored, and that his blood pressure was low. I recall his heart rate being monitored. I remember a pulse oximeter on David’s finger, but I cannot remember what his oxygen levels were or how long he tolerated the pulse oximeter for. I did not see any clinician listen to David’s chest. I did not see any clinician examining David’s pupils. I did not see any clinician examining David’s limbs to check for any signs of injury”.

Keri left the department for a short walk and to get some air, when a nurse suggested she do so as they were changing David’s sheets as he’d passed urine whilst sleeping. She did so and told the court when she returned the nurse was getting ready to move David to the Acute Assessment Unit.

“I enquired about how he coped with his bedding change, and they said he was fine. I cannot clearly recall but I think the nurse told me that David had been given some more sedative medication and that this had been Lorazepam, however, I am not 100% sure about the dose or timing of Lorazepam.

I enquired about Paracetamol, and they said it would be given on the Acute Assessment Unit. I thanked them for their help and accompanied David to the Acute Assessment Unit, where he was taken into a room”.

Keri said she completed some admission paperwork with a nurse on AAU and asking her if there would be more fluids, as the current bag was finishing. The nurse told her that the doctors would be coming around to talk to Keri “when they could”.

Keri said she returned to sit with David and he remained asleep. At some point in the early hours David’s breathing changed, and she sought help from the nurse sitting at a desk across from David’s room.

Keri recalled staff rushing in and starting CPR. She described being joined by a Matron from the Critical Care Outreach Team who sat with her.

“I recall talking to her about David and I recall that she was very kind”.

Keri said the doctors from the resuscitation team “in what seemed like no time at all” came into the room and explained they had successfully resuscitated David after 8 or 9 minutes and he now had a pulse and was breathing for himself.

“I recall one of the doctors explaining that we needed to make a decision about what would happen next, in other words, whether he would have any escalation of care such an intensive care. I recall asking what would happen without this, and the doctors saying he would be given any treatments he needed, like antibiotics if he needed them, but that the likelihood was that these would be supportive measures and that he would die in the next few days.

I recall asking if there were any reversible causes, for example, had he been given too much sedative medication and did this need reversing, and the doctor explaining this was not the case as David had received Lorazepam in the Emergency Department and the effects of this would have worn off by now.

I recall the doctor explaining that David’s body was frail after what he had been through over the last couple of days, and that he would have experienced further hypoxic brain injury whilst in cardiac arrest, and as such, the outcomes of further care, such as transfer to intensive care, were unlikely to be good. The doctor did not make any mention of pneumonia.

I clarified that the decision was not just being made on the basis of David’s chronic disabilities, and they said this was not the case, and it was about how frail he was now and the brain hypoxia whilst in cardiac arrest. The medics felt David should not have further escalation of his care.

I explained that my dad would have wanted them to give David the chance of ICU and asked them to talk to our mother. I recall the outcome of the discussion was that David would not be offered any further escalation of care, that he would be kept comfortable, and that my mother was on the way to hospital”.

Keri then described returning to sit with David, the Matron waited for her mother. She asked the nurse to put the bed side down so she could get close to David and sat holding his hand. When her mother arrived she sat on David’s other side.

“I recall that around 4am, to the best of my recollection, a nurse told me David had passed away and that she was sorry for our loss. I recall pointing out that his eyes were still moving, and telling her that I could still feel both his radial pulse and his heart beating.

I am not sure what the time of death was given as, but I do not think he was dead when the nurse said he was. I continued to sit with him for the next couple of hours as he became colder and eventually his eyes stopped moving, his pulse stopped, and I could no longer feel his heart beating”.

Keri’s statement moved on to discuss her concerns about the medical care David received.

“My concerns about aspects of David’s medical care contributing to his death are based on my observations when supporting David in hospital immediately prior to his death, which are themselves informed by my professional knowledge, along with his interim death certificate information”.

The concerns Keri raised included her surprise to see bilateral pneumonia as cause of death on David’s interim death certification.

“There had been no mention of pneumonia by any of the health care professionals involved in David’s care at the time of his death. I also thought how, when David previously had pneumonia, he had a bad cough. I am left wondering was David already so severely compromised by pneumonia when I found him that it was affecting his respiratory function and that he was not able to cough? Should this have been detected earlier and should he have been given oxygen in the Emergency Department?”

She said she had seen no examination of David’s chest or his respiratory system, apart from pulse oximetry, undertaken by any health professional involved in David’s care.

She wondered given David had been found on the floor, was very weak, his previous history of aspiration pneumonia requiring ventilation in ICU and childhood asthma, why there was no respiratory examination.

She also raised that she saw no full examination of David for potential injuries by those involved in his care. Paramedics had noted the bruising to his head and unilateral constricted pupil when preparing to transfer David to hospital. Keri told the court she had raised concerns with the ED Consultant about potential head injury but these were dismissed.

She raised that there had also been no examination of David for signs indicative of other injuries, despite him being found on the floor after a long lie and potential fall.

She had concerns that David received no pain medication despite her repeated requests.

“I specifically asked for paracetamol a number of times, but to my knowledge, this was not given. I am concerned that if David had been experiencing stress from being in pain, this may have contributed to his body going into cardiorespiratory arrest. I cannot understand why he wasn’t given the simple pain relief requested, and I would not want anyone else who cannot speak and may struggle to express their pain to go without pain relief.

I still do not understand how David went from the Emergency Department consultant telling us that we would be discharge-planning the next morning, to going into cardiorespiratory arrest and dying a few hours later”.

Keri said that she had asked one of the doctors from the resuscitation team if there were reversible causes for David’s cardiac arrest, and whether he could have experienced respiratory depression from too much sedative in the Emergency Department. She said he assured her that was not the case.

“I am left wondering if things were missed, such as pneumonia, head injury, pain, and whether, had they been identified and treated in a timely manner, David might not have deteriorated in the way he did.

Ultimately, my question is: was David treated differently to any other 40-year-old man presenting in a similar way, as a consequence of his learning disability and autism; were things missed; and did this affect the outcome?”

As mentioned in the coroner’s opening, Keri’s concerns about David’s social care were ruled out of scope of this inquest. There was one part of that section that Ciara Bartlam had requested included, and as such it was read onto the record.

“It is my view that David’s care plan did not plan for emergencies in an effective way. David was failed by not having access to a means of raising the alarm. One key question I have is: how many other vulnerable adults in Hull with a learning disability and/or autism, and/or visual impairment, and/or immobility, have care plans which do not address how they themselves will raise the alarm in the event of an emergency, for

example, if something unforeseen happens to their carer? I would not want anyone else to go through what David did in his final days because of not having a means of raising the alarm.

I recall my mother and I asking about lifeline alarms or pendants for David in a meeting with his social worker several months before his death, and it being discussed that David would not tolerate wearing a pendant lifeline alarm.

I am left questioning whether the limited exploration of means for David to obtain help in an emergency left David at risk. I am aware that Humber Teaching NHS Foundation Trust has previously developed other Apps for day-to-day care of people with a learning disability, and I would hope that in the light of this inquest, and in David’s memory, they could develop an accessible App for people to be able to raise the alarm in the event of an emergency. I believe that David would have been capable of using such an App. I have also been looking into existing Apps which mostly appear to be designed with elderly people who live alone in mind, and I believe that David would have been able to use some of these Apps, for example, Red Panic Button App, which could have been added to his tablet”.

That was the end of Keri’s evidence to the court. At that point the court was adjourned for a mid-morning break.