The first person to give live evidence at David’s inquest, on Day 1, was Dr Fraser Young who is an Emergency Medicine Consultant at Hull University Teaching Hospitals NHS Trust.

[This evidence was given yesterday but I’ve only managed to report it now due to the fact there is only one of me, and a lot of evidence, apologies for the delay]

The coroner said Dr Young had given two statements, the first dated 22 March 2022 which was a 3 page statement in which he gave “a little bit of chronology” and the second, a further 5 pages, dated 12 February 2023 in which he responded to some of the concerns in relation to those raised by the family of David.

The coroner said he would ask questions first, then the representative for the family, and then the Trust.

C: You were on duty in the Emergency Department on 12 January?

FY: Yes, 4pm to midnight

C: right, so you’ve had a refresh of your memory in relation to your statements before this hearing is that fair?

FY: Yes

The coroner asked him to talk the court through what happened, starting with the arrival of David by the ambulance service.

FY: David arrived into our initial assessment triage area, I’d not met him, he was seen by the triage nurses, who had taken a handover from ambulance service and I believe had conversations with Dr Lodge

Concerns at that point was dehydration, possible injuries, the Charge Nurse came to find me in resuscitation area of the department with particulars of the case, and I came through very shortly after that to meet David and Dr Lodge

C: I tend to ask questions and interrupt at points to get information… time, on your statement its 16:33 he arrived at the initial assessment area, seen by triage nurse at 17:19 and you attend to make ab assessment at 17:21?

FY: Correct. I had quite a long conversation with Dr Lodge, in relation to statement we’ve just heard, must be upsetting going through that, gave a lot of particulars of David’s medical history, his needs, his normal communication through the Lightwriter, which we had but wasn’t working at that point, don’t think I was aware that was because of charge, but we formed a plan. Had a bit of a discussion about agitation, carried on from ambulance crew being unable to get any blood pressure, worked through that, what was in his best interest to start getting some observations and treatment for likely dehydration and [missed] given history. That in my opinion suggested we should give him a dose of sedation. He’d had sedation for medical procedures before.

C: that’s a lot of information… please refer to Dr Lodge as Keri… You’re given medical background by Keri, and then you’re given background in relation to David’s dad as well, that’s mentioned in your witness statement. Then you talk about sedation and said full observations not possible. Help us with that.

FY: An attempt at physical observation was not made on the marker he was not able to tolerate the blood pressure cuff or monitoring so made [missed] undertake that without giving some form of sedation, to facilitate all those things in one go in as timely fashion as possible.

C: What normal observations would you conduct in a scenario like this?

FY: Full set of observations via machinery, oxygen levels, respiratory rate, GCS or if not possible alert voice.

C: GCS in plain English?

FY: Glasgow Coma Scale or xx scale where communication is difficult, temperature, blood pressure and probably blood sugar

C: ok, and mobility? Things like that?

FY: Depending on presentation, in particular we’d had discussion about possible bruising on side of head, would likely have look at head and examine for any other injuries

C: Which of those were conducted and which were you not able to conduct? You mentioned attempt at physical examination was not made, not able to tolerate blood pressure?

FY: I believe temperature, not entirely sure prior to my attendance, which observations were done by us or given to me by the Ambulance Service in transit to be fair

C: Taking us through it, you said observations by machinery, GCS or [missed], temperature and blood pressure. You talked about not being able to do blood pressure and ECG monitoring and mobility as well. What’s the initial situation in the preliminary period during your first consult, what’s your view or otherwise in relation to those things?

FY: With regards the information I had?

C: As treating clinician with the patient in front of you… applying that position, general position into this scenario, to extent mentioned couple of things couldn’t be achieved, what’s the situation in relation to other things, consciously not considered?

FY: Preferably would like to have all these things. I guess we were unable to achieve from triage as a result of his agitation, issue with continuing to make multiple attempts to do that would increase agitation. Keri and I had conversation about previous hospital experiences, not withstanding the most tragic and horrific situation of previous days, it was my assertion we should get everything done correctly, with dignity to him. We’d provide sedation non-invasively, not approach him with a needle, some oral liquid.

C: Is this your entry at the top of page 23 of your statement?

FY: That’s right

C: Before we get to that, rolling back a little bit. If we say on your evidence you began the assessment at 17:21, and sedation occurs at 18:25, that’s 1 hour and 4mins… in terms of agitation then, what was the extent of it, can you remember?

FY: I can recall the scene, cubicle 6. My initial assessment at 17:21 was predominantly talking to Keri at David’s bedside. He was wrapped up in blankets, when not approached or touched he was settled. Keri had conversation about how she’d found him and he was a bit subdued, obviously in tandem with the Ambulance Service handover which was he was quite agitated.

C: How did the agitation manifest itself?

FY: I personally didn’t witness that. It was reported to me he was fighting off the blood pressure cuff

C: So when he was with you at 17:21, in relation to agitation you didn’t see signs of agitation?

FY: No. I didn’t touch him, we stood at the foot end of his bed space, at a time we moved away to have a conversation about Peter, couple of other items, not in the ear shot of David

C: Alright, in relation to things you couldn’t do on ordinary observation… the reason for that being his agitated state, is that right?

Dr Young nods

C: The basis on which you’re operating he was agitated, it’s not a criticism, but was effectively the position given to you by the Ambulance Staff and by Keri?

Ms Bartlam interjects to say that the witness is speaking very quietly, the Coroner agrees and says that you have to throw your voice into the room. The Coroner’s Officer moved a microphone onto the desk.

C: I was asking you about reason for the basis you considered he was agitated, it wasn’t what you visualised, it was from what was told to you by the Ambulance Staff?

FY: And my Charge Nurse, whose reason to come find me was to tackle the agitation … concern unable to get these things to formulate a plan

C: step back, the Triage Nurse would take the observations and then the Consultant would form a view on next steps, observing the outputs of the observations. You’re saying the nurse couldn’t do observations, so you were called upon because they couldn’t proceed as they couldn’t triage?

FY: Yes, they were unable to triage or incomplete triage as it were

C: It says in your statement, I don’t think is controversial to refer to it:

“I discussed David’s immediate foreseeable needs with his sister, it was agreed that at the time the best course of action was to provide some sedation medication”

Help us with that?

FY: In terms of conclusion?

The coroner asks him to explain his thought process.

FY: Essentially on the face of it, he’s clearly dehydrated, likely he’s not eaten or drunk anything without Dad’s assistance for multiple days. We want to get IV access, only options are to have several people forcing that upon him, or to deliver sedation with attempt to get that shortly afterwards.

We discussed that, in my opinion holding someone down forcing care would be a last resort, doesn’t provide dignity in care, in context of previous difficult hospital encounters as inpatient and outpatient

C: So, the method is calm him down and do the observations your Triage Nurse couldn’t do at the beginning?

FY: Yes  

C: In relation to the 18:25 dose you give him, help us with the efficacy of that decision.

FY: From initial assessment we spent 15 minutes discussing sedation

C: Yourself and?

FY: Keri… I wanted to get a sense [missed section]

Subsequent to that given oral buccal midazolam would not be preferred route given patient dehydrated, wanted to double check potential dosing, and sense check plan with another colleague.

The other colleague present at the time, in the department for another reason, was near the area where I was checking dosing guidelines was an ICU consultant who had previous knowledge of David during his ICU stay in 2021, and had been involved to some extent with his dental clearance work

C: Can I check is this mentioned in your witness statement?

FY: No

C: Can I ask why? It’s not a criticism

FY: Essentially, I made the decision of medication, I did sense check it with someone else

C: Which is usual practice

FY: Yes

C: So, prescription is authorised for sedation medication, what was your next steps in your thought process?

FY: Next step move from initial assessment area to majors area, the main area of the department, to go to an observed room, a room with full continuous monitoring ability, and is open to the doctors and nurses area. We have numerous rooms which are less visible, so moved to a more visible room.

C: Still on the Emergency Department?

FY: Yes

C: You mentioned full continuous monitoring ability, obviously ability and what occurs are potentially two different things. What’s the situation with continuous monitoring in a room such as that?

FY: In David’s case when he first got in there, we were waiting for the sedation to take hold, subsequent to the sedation working then it would essentially be on a monitor which has pulse, oxygen levels, blood pressure. Pulse and oxygen levels continuous, blood pressure circles every 5, 10, 15 minutes depending what it is set to and is displayed on various monitors around the department

C: So, any passing physician would be able to see his outputs. So when you refer to continuous monitoring it’s not by a person as such, but by the machine?

FY: Agree, continuous observation that allows monitoring of that would be a better vernacular. Obviously when the nurse does regular observations and records those in NEWS [National Early Warning Scores] score for example, those are taken from the monitor, snapshots in time. So five sets of observations taken over 3 hours, for most part the monitoring was on continuously, and being looked at, passed, checked on.

C: So, where we have the NEWS score outputs and times allocated to them, what’s the value if your evidence is you have continuous monitoring anyway?

FY: As a matter of record more than anything else, national best practice… the problem with continuous monitoring is unless someone writes them down, the record doesn’t mention they’re taken

C: So, in other words someone passing would look at the monitor, this is what the monitor shows at this time and write it down. So continuous for whoever is in the room, but written output is timed?

FY: Monitoring is continuous, but recording is periodic

C: We want to be careful, monitoring by machine is continuous but we don’t have someone watching all the time, we have periodic snapshots of it?

FY: I agree yes

The coroner said that he would do the NEWS scores as he goes along. He said he’d taken an uncontroversial output from Dr Athey’s report where he summarises the outputs at the top of the page. He said he did not think it was controversial to show the witness that statement, asking Ms Bartlam. She agrees. Ms Lyle told the court that she had indicated to the Coroner’s Officer that the statement might be shown.

Dr Young is given a copy of the table.

C: I think Mr Athey’s presentation of it is amazingly simple, I’ll work from that. We’ll interpose your evidence with the NEWS scores. The first one, ten minutes into his time with you is taken, is that fair?

FY: Yes. 17:32 observations, respiratory rate of 24, refusing blood pressure, oxygen sats 100% on air, noted he was alert, unable to record temperature and recorded no pain.

C: and is the EWS column where it says 2 in green highlight is that where we get the NEWS score

FY: Yes, EWS is early warning score

C: that’s given as 2. In relation to that, that’s occurring on the basis of what you said with Keri, whilst you’re having a conversation with Keri?

FY: I can’t recall the nurse doing observations in front of us while we were having a conversation. Reasonably sure we were having conversations at David’s bed and for brief moment after that, off to the side of him

C: When you were talking about Peter, yes. OK, nevertheless it’s before the 18:25 sedation medication is given. In period of trying to work out what’s going on with him, will put it like that. What’s your interpretation of that score?

FY: The score of 2 is inaccurate, can only calculate based on observations been put in. Will give 2 for respiratory rate being 24 but not for any that are unable… if it’s not done it doesn’t numerically show on the system.

C: OK, so little value, is that the output?

FY: I wouldn’t infer a huge amount from that, would have more value in fact clinically he looked dry and his reliable history from next of kin that he was not his normal self

C: ok, trying to do chronologically, next score is 20:53 in that table, that’s essentially the next part of your evidence anyway if taking through your statement. You say further to earlier plan ED staff nurse was keeping David under observation following sedation and managed to obtain observations at 20:53. Help us with, is there anything in the interim you would want to note from the 18:25 sedation up to the 20:53 NEWS score provided?

FY: From my side specifically, no. Was handed over to Nurse whose name is at the top of the chart, that was the plan, once could get set of observations let me know and I’ll continue with the plan. The timespan is not a reasonable one I’d say in retrospect.

C: Obviously someone comes into the ED at 16:33, so half past 4, it’s now 8:53pm, we’re talking 4 hours 20 minutes’ish. That’s in retrospect quite reasonably long?

FY: To qualify with regards medication given, I’d have expected in most people, given medication for sedative effect some time sooner than that. I can’t within the available information account for that, whether that’s when the nurse was able to go back and check, I don’t know.

C: So, sedation 16:25, observations just shy of two and a half hours later, is that a reasonable time frame for medication to take effect or are there variables?

FY: Always variables, in lots of cases. Potentially reduced circulation, previous exposure, we had conversation about sedative medication, I would have thought at the 2 hour mark we’d have reasonable, would have hoped at the 1 hour mark, including moving him into a more tranquil space with door to it, visible but much calmer than triage area…. Having combined effect.

C: I appreciate you’re not the nurse, your responsibility is to view the output, it’s the nurse that completes the observations?

FY: Predominantly yes. I’d have this amongst all my responsibilities, I gave medication, so it’s my responsibility to check the response, the conversation we had was nurse would inform me when observations had taken place and we’d be able to get IV access

C: Should these observations have happened sooner?

FY: I don’t know what occurred in that period. I don’t know if tried and failed and not recorded. I don’t know if they weren’t done earlier because of busyness or acuity. I don’t know.

C: Moving onto 20:53 score, can you help us with interpretation of that please

FY: Yes, respiratory rate of 17 and oxygen sats of 99 in air, blood pressure 79/54, heart rate of 72 beats a minute, was responsive to pain, temperature of 33.8 and NEWS score of 9… that represents the true baseline of observations.

C: Because earlier one is incomplete, now had sedation medication, got machinery connected and this is effectively your first reliable scoring?

FY: Yes slight foible, people score point in response to pain rather than being alert, when agitated previously was recorded as being alert

C: How is pain tested?

FY: It can be various things, certainly not going off inflicting real pain, essentially physical touch, a stimulus, attempt at blood pressure management in someone asleep, inflated BP cuff and woke up, technically that’s response to pain.

C: So very minimal touch can get you onto that?

FY: Can do, some interpretation, if you were asleep I said your name and you woke up I’d say alert, if tapped your shoulder… one of experts alluded to some are hard facts, numerical items and some are subjective.

C: And you are looking at this scoring, when? Obviously, that’s the time it’s taken, written down from continuously recording machinery. What’s time difference between that recording and you having sight of it? If you recall?

FY: About 7 minutes or less. Nurse who performed observations came and found me, I had IV access and took bloods at 21:00 so between those observations being taken and me doing bloods I’d have explored those observations

C: Bloods then taken, that’s where next witness comes in shortly, in relation to interpretation of those. You mention this in your statement, and what’s your thought process at this stage then, you’ve not got this scoring, credible reliable scoring and you’ve taken blood?

FY: Taking a step back from blood tests performed at same time, the concerning feature there is significantly low blood pressure, concerning feature, corroborates someone devoid of fluid volume. Dehydration in this case, quite significantly low, although not surprising. Diagnosis building up from history here.

C: Help us with the diagnosis

FY: From history knew he had not had access to food and drink for approximately 4 days, think all noted that was significant factor in the concern of his current health picture. That would corroborate that.

C: In your statement, my eyes falling to paragraph a diagnosis of hypothermia, acute kidney injury. That was when the bloods come back?

FY: Hypothermia is known at that time, the acute kidney injury is not known until the laboratory bloods come back. We did blood gas, small sample gives PH, that result within minutes, laboratory results then take between half hour and hour depending on how busy they are.

C: OK, what about the scoring of 9

FY: Its high, it’s a high early warning score that needs acting on appropriately, as an early warning

C: And in relation to that acting, how does that, taking bloods to get further information?

FY: IV access essentially, taking blood doesn’t help David at that time. Getting IV access and commencing warm IV fluid and active rewarming using a bare hugger blanket [missed]

C: Is in relation to your view of this score then and action taken and appropriateness of that. You’ve taken score, working diagnosis, conducting further tests, will be some delay, not a criticism is the function of getting results back. In meantime because of temperature, you’re operating to rewarm him and get fluids in?

FY: Yes, rewarming because that’s hypothermic, that’s measurable, and support blood pressure with IV fluid with working diagnosis of dehydration with view blood tests will confirm or deny that and response to that therapy will confirm or deny whether that was reasonable working hypothesis.

C: So, you’ve got further … you’re taking action to deal with the things you currently see in front of you?

FY: That’s correct

C: What’s your view, IPs have provided document that speaks to interpretation of NEWS scores. Don’t know if you need a copy of it?

Ciara Bartlam says she has a spare copy of it and provides it to the witness.

C: Open question, what’s your view of the result you got back and applying. First of all can you help us with the applicability of this document.

FY: It applies in pretty much any Trust I’ve worked in, plug observations in and action points to it

C: So it’s not that it applies to some trusts and not Hull?

FY: No, is a national thing, largely NEWS scores and action points are more nurse led than doctor led, I’m usually the person who the escalated high NEWS score is to

C: You were the person who makes the decision, Nurse conducts the work, you’re the Consultant?

FY: Correct

C: So, help us in relation to generating NEWS score, you’ve obviously mentioned you had particular concern arising out of this score of 9. Are there different factors that contribute to that score which would result in different views by you?

FY: Yes

The coroner asked Dr Young to help the court with that by explaining further.

FY: In this case the NEWS score of 9, largely weighted to two domains, three I suppose with response to pain, hypothermic and significantly low BP adding up to 9. We frequently see patients with NEWS scores of 9 with every domain slightly abnormal, may result in different action points, depending on specific measure as well, if high respiratory rate and low oxygen would be different chain of events. If anything from this NEWS score his respiratory function appeared to be normal, his cardiovascular system was not normal, so want to make intervention for hypotension in this case.

C: In relation to that, multiple points in my mind, in so far as you’re the recipient in ED of the output of this result, what I’m getting at, varying things contribute to the score. Score of 9 doesn’t necessarily mean every patient is in the same position as David is in here?

FY: No

C: Different things could contribute, would there be different actions that materialise in terms of what factors generate that figure? It’s a broad question.

FY: Of course, my job is to interpret that and make an appropriate treatment plan, what contributes to NEWS of 9 in David’s case or another patient when a different 9

C: Follow through in general terms, the proposition you’re aware of, expert reports, is in relation to what actions taken, whether or not there ought to have been sending of patient to another… if over certain number, should you necessarily be looking to send the patient out of the Emergency Department to another ward?

FY: I think it’s quite a difficult question to answer without specifics, will be sometimes yes and sometimes no

C: I’m trying to apply my mind which of the two this is… there are, let’s do it like this, your evidence is circumstances in which with NEWS of 9, not necessarily David’s case, you’d retain conduct of the matter, you’d keep with you, rather than send to AAU. Just explain, does that make sense?

FY: Absolutely, I think depends on the trajectory and response to appropriate treatment. Take numbers here NEWS 9 and blood pressure 79 systolic, would not be happy with him at that moment, bag of fluids or otherwise, to go to the ward, would have to stay with us for check response, that will either improve or it won’t, if it doesn’t would have different set of escalations thereafter than if it did.

This case… fluid therapy on working diagnosis pending other results to broaden picture a but, might be happy to let him go, if NEWS score reduces considerably, then is appropriate to go to the ward. Different levels of that, go to ward, having prior seen or discussed with plan… again very specific case dependent.

If NEWS score is 9 and BP is 70 systolic that did not improve from initial therapy, then that would be reason to consider referring to ICU, or starting isotropic medication in addition to fluid to support BP.

C: So, am I right to interpret on your evidence, it is available to you to exercise discretion, you’re not following distinct tramlines of a policy document somewhere, based on observations of his trajectory is developing or otherwise. It’s the follow through if NEWS score comes down he’s still in ED territory, and possibly send on somewhere else?

FY: Yes, frequently patients have NEWS score of 9 or 10, get better and will send to an acute medical ward, if don’t get better in A&E department will keep and escalate to Intensive Care or specialist teams depending on corollary.. as a slight aside to that, the NEWS score isn’t the only part to that matrix

C: Help us with that please. His blood gas findings, his metabolic status, your PH, other blood tests, electrolytes, how do they generate some light on the fog?

FY: If someone is severely acidotic my job is to work out what’s causing that… address that at the time, or if it becomes apparent during admission address that then…. Or escalate that to medical registrar, the ICU registrar.

C: Applying that onto David then, you have situation here, at 20:53 and minute after 9pm bloods being taken. You’re still in the territory where it’s appropriate to keep him where he is?

FY: Yes, on base level apart from the delivery of sedation, that was a bespoke plan for David. I’ve not delivered any treatment yet … that’s where treatment started, so it wouldn’t be appropriate to move patient on immediately having just commenced treatment.

C: So you need to give it some time?

FY: Correct

C: So, your view of output of 9 NEWS score, is keep him where he is, we’re testing and taking further bloods. We just need to monitor him?

FY: Yes, overlap NEWS of 7 or more, assessment by a team with critical care competencies, including practitioners with advanced airway management skills. I am one.

C: You’re reading from the document handed to you?

FY: Chart 4 Clinical response to NEWS scores

C: 7 or more applicable here because he’s on 9. Continuous monitoring of vital signs.

FY: That’s what we were delivering in the cubicle in the department, until it was appropriate to move to a ward environment.

C: Bullet point three, consider transfer of care to clinical care facility i.e. higher dependency unit or ICU. Help us with your observations about that between 2053 to 2100?

FY: I think David was absolutely appropriate for ICU, no reason not to refer him to ICU facility having been there a year prior. I wouldn’t routinely, our department wouldn’t routinely refer to ICU having not delivered any treatment first. If we did that ICU would come back and ask what treatment we’d given … they’d advise give some treatment first and we’ll see how we go.

C: So, your thought processes was you’d be considering ICU as per that document, but you’re not of the view he needed to go there because of reasons given

FY: He didn’t need to go there immediately

C: At 21:00 at that time, you’re not then of the view because you’ve only just initiated the things you’re talking about?

FY: Yes

C: OK. So, in relation to this document, the second bullet is assessment by a team with critical care competencies, that’s you, so in relation to compliance with this you are complying with it?

FY: Yes, and unbeknownst at the time, when NEWS was 2 the nurse recognised she needed to escalate to me.

C: So that is an example of escalation and compliance… she’s raised it with you and then you’ve introduced the sedatives to conduct the observations, you wouldn’t send him elsewhere before that.

FY: No, you wouldn’t introduce a sedative and then transfer a patient anywhere else, there’s a period of monitoring after that.

C: Your clear view at this stage, no issues with it, you are employing the NEWS Guidance, that’s your clear guidance isn’t it?

FY: Yes, action on the basis of NEWS score and the clinical picture, not solely practicing medicine on the basis of NEWS scores

At this stage the coroner suggested a lunch break. Ms Bartlam raised the possibility of making enquiries about the identity of the ICU Consultant who Dr Young spoke to, and whether they are able to attend court tomorrow.

A lengthy discussion followed between the coroner and Interested Persons representatives about the best way forward.

The coroner asked Dr Young who the ICU Consultant he had spoken with was. He confirmed that he was called Dr Harish Lad and that he was still working at the Trust.

It was agreed that Dr Lad would be asked to make a statement and give his availability to attend the inquest tomorrow.

The coroner warned Dr Young that he was under oath so could not discuss his evidence with anyone during the lunch break. Court adjourned at 13:18 for an hour.

On return from lunch there was further discussion about the new potential witness. Ciara Bartlam informed the coroner that he would notice Keri was not in court, that she had found the morning difficult and would return to court tomorrow. The coroner said that he had realised he had offered his condolences on David’s death but ought to have passed them onto Keri for her father’s death as well and asked Ms Bartlam to pass those on.

Then it was back to the coroner asking questions of Dr Young.

C: We were discussing observations taken at 8:53pm, NEWS score of 9. You visited afterwards, we know so because you took blood sample at 9pm.

From 9pm then Dr Young, can you help us with, you have a working diagnosis, at some point you retrieve the blood results, the next witness will speak to, can you help us with what your next positions are?

FY: Following blood results or before?

C: If anything to say before, then say so.

FY: Before performed blood gas that was first time I put hands, physically touched David. I would say from earlier readings from Keri’s statement, I did peripherally take his pulse and look under covers at his abdomen and limbs to ensure was no injury from fracture.

C: Is that at that time?

FY: Yes, when I went in the room for blood tests to be taken.

C: Let me look at your statement, you say at this time Mr Lodge significantly more relaxed… further blood demonstrated that and you go on. Are you saying at this time you did examine him?

FY: At the time I went into the room, I did inspect him externally.

C: Would that be something you’d ordinarily include in your witness statement?

FY: It’s a negative finding, so I wouldn’t necessarily include it, if it was a positive finding I’d have mentioned it.

C: Is there a contemporaneous record of what you did at the time? Would you record these negative findings in your contemporaneous records?

FY: I can’t remember, I believe I only interacted with the computer record once.

C: To be clear your evidence is, it is not included in your witness statement or contemporaneous records, but you did inspect him to ensure no injury, you looked at abdomen to ensure no swelling, or fracture?

FY: Abdomen and limbs

C: What was the result?

FY: Was no obvious finding, aside to the slight bruising mark to the head I’d noted, or had been noted previously by myself, Keri or the ambulance.

The coroner said he’d deal with head injury and asked Dr Young on what basis he was giving his opinion on head injury, whether it was on the basis of his 9pm examination of David or further occasions.

Dr Young responded it was on the basis of both the initial assessment he started at his first consultation when Keri and he were at the foot of David’s bed, and from walking past and interacting process.

In response to further probing from the coroner about how he assessed for head injury Dr Young said it was why he had noted that David was moving all 4 limbs. He said with a brain injury swelling a patient would become bradycardic and hypertensive (slow heart rate and raised blood pressure) but in this case it was the opposite and David’s blood pressure was low.

Again following further questions from the coroner Dr Young said David had “no head injury that required immediate action or intervention, he had bruising to his head so by definition that’s an injury” but he told the court he was “comfortable not to go down the route of a CT head scan”.

C: So, you considered a CT Scan and discounted it?

FY: Yes, I spoke in my addendum statement, I did talk to Keri about that, CT Scanning, positive value of that versus observing for any signs of deterioration from that respect, part of the process of trying to balance what needed treated now, what could be investigated later… the pressing issue for me was to treat the hypotension.

C: OK, we’re now at the 9 o’clock mark. Another NEWS score at 21:37 hours… blood results back 21:47. Anything happened chronologically before 21:37 we ought to be discussing?

FY: From a treatment perspective fluid was prescribed, would have to consult fluid charts to check started between 9 and 9:37pm, it should have done, but wouldn’t be that far into that period.

C: Help us with that then

FY: 2 litres of clear, warm fluid, run consecutively, the nurse would attach it and give to patient, and I believed commenced on the bear hugger device, which is a rewarming device essentially

C: Alright, the 21:37 NEWS scores, help us with what those are, and your interpretation are

FY: 21:37 score is 9, respiratory rate was 16, his oxygen saturation was 97, his blood pressure 76/55, responsive to pain and temperature of 33.6

C: What is your observation in relation to temperature or any trajectory patient was on at this stage?

FY: At that stage was same essentially

C: What was your thought process in having another 9 NEWS score?

FY: Clinical position remains… he’d not had enough treatment, fluid would take a couple hours to give, some method to bring blood pressure up but potentially not rehydrating someone who has taken several days to become dehydration… reperfusion risks were discussed …

C: So is another way of saying what you just said, there’s a function of the period he was … are you saying period time takes to rehydrate should be cognisant of time, don’t want to rehydrate too quickly?

FY: In most cases yes, if unconscious because of blood pressure this low, or producing no urine at all you’d want to hydrate that a bit quicker, need to judge in context. The difficulty is to want to add more treatment, but if you give all at once, have to deal with the consequences.

C: Are you saying at this stage you were worried or you’re still generating a picture?

FY: 21:37 from 20:53 I’d expect the NEWS score to be similar

C: So you weren’t surprised by this NEWS score?

FY: No, no, nor advanced nor anything over the next hour or hour and a half.

C: Right and what was your view in relation to what you should be doing in receipt of that NEWS score at 21:37?

FY: Make sure the Treatment Plan was actioned, we were rewarming and giving fluid. I had a further discussion with the Medical Registrar and with Dr Chase, actually going back a little but in this timeline. Prior to 8pm I did have a conversation about David with the daytime registrar, say this is situation, this is where we’re at, I think we should see him at some point prior to transfer. Daytime registrar did indicate was close to finishing time and said would hand over, subsequent to that when Dr Chase and I spoke I don’t believe that was handed over.

This was prior to blood results, this is situation, blood pressure is quite low, on fluids and actively warming.

C: Just go to your statement for a moment … Dr Chase is the overnight registrar?

FY: No, that’s two different things, Dr Chase is registrar for AAU, that’s who replaces me.

C: fine, but you’re saying you had a conversation with Dr Chase?

FY: Yes

C: When was that sorry?

FY: Just after the blood gas, then we had a further conversation after I’d reviewed the rest of his lab results, just after 9pm, that was more of what the situation was, what background was, and current assessment and what treatment I was giving.

C: Help us with why you had that conversation with Dr Chase?

FY: Twofold, internally anyone with a moderate or high NEWS score with any pathology we’d want the speciality doctor responsible for them to be involved in their assessment… bringing some of the functions of the Acute Assessment Unit to the patient in ED first, before moving the patients to another environment

C: Does this speak to not wanting to move someone when having fluids?

FY: In this case yes, in other cases can be where there’s some diagnostic uncertainty. Information can be hard to capture…

C: Bear with me one moment please. So, you now have got a couple NEWS scores at 9 by 21:37 and your evidence is that’s not a surprise to you, still waiting fluids come through, then get blood results. Talk to us about the blood results then.

FY: From my statement… stand out features were significantly raised urea count, part of kidney function in terms of excretion… normally indicate significant dehydration as cause. Dr Chase is specialist in kidney function subject but that concerns dehydration is primary cause of this. Also did note in my addendum statement, lab results came through highlighting this is an acute kidney injury

C: And 22:29 we have another NEWS score, help us with that please.

FY: Is again, quite similar, almost identically similar to previous ones allowing for measurement error. NEWS score of 9, respiratory rate of 16, oxygen saturation 98, his blood pressure was 73/57, heat rate 85, responsive to pain and temperature 33.8

C: So, you have another NEWS score of 9 and your evidence is at this stage you’ve liaised with Dr Chase. I should have asked what outcome of that conversation was?

FY: First conversation before blood gas was significant background, and I’d asked her to see the patient in the ED. Second conversation was updating her to blood results and where we were at, starting a second bag of fluids for example.

We did have conversation the same, would like Dr Chase to see the patient. Had sensible conversation about immediate priority and urgency, several other things in resus that Dr Chase was doing. We agreed had diagnosis and treatment plan, so address those first and then catch up with David subsequent to that. That was my belief as a result of that conversation.

C: Did that eventuate? Was there a meeting with David on ED by Dr Chase?

FY: I don’t believe so, no

The coroner then asked further questions of Dr Young about his plan when David had another NEWS Score of 9. Dr Young was unable to recall where they were in terms of initial treatment that had been given to David at that point but his recollection was that they were continuing with treatment. Ms Bartlam was able to assist with the provision of a record of the fluid chart.

Dr Young confirmed at 22:29 David had only had 1.5 litres of fluid at that point, adding “I’d hope to see some response to that at that point”. He then added a point about the requirement to balance the need to treat David’s hypotension with fluid, whilst rewarming him externally, explaining that the rewarming process was likely to lead to someone’s blood pressure dropping.

The coroner sought further clarification.

C: the nub of what I’m getting at in this period of time, we’re talking 22:29 and following that. We’ve got 23:07 with another 9 and the 00:48 8… help us with your thought processes here, are you still operating in your opinion in line with Chart 4 requirements?

FY: I don’t think at each interval when these observations are recorded on this system, that resulted with the nurse immediately coming forward with a new set of questions, because we were already in an elevated position. Nothing new was raised to say we’re going downhill, I don’t believe we were. There’s quite slow progress, towards improvement, but nonetheless I believe that does occur.

I think also with several conversations with our nurse who was looking after the patient, same nurse throughout, who was very attentive, as to how was he doing. How he was doing, looking in terms of his colour, responsiveness, is more than a package of just what the NEWS score tells you although I appreciate it’s the only objective thing we have to make comment on.

C: So, in terms of the NEWS score that’s a partial indicator of what your view would be, would be operating on other things, colour of person, responsiveness

FY: Uh hum

C: Tell us responsiveness, what do you mean by that?

FY: He’d had some sedation, but a patient hypotensive who is rewarmed and starts to feel better… would start to be more responsive, in this case, once sedation wore off. That’s true and he did become much more responsive, that’s 00:48

I missed the coroner’s next question, apologies. Dr Young said at 00:48 David was becoming more alert and Keri alerted staff that he’d “ripped his blood pressure cuff off”. Dr Young said he liked that as it was showing that David was more aware, but that had to be balanced against the risk of him taking his IV out.

The coroner asked if Dr Young’s shift had finished at that point. He said that at midnight there was a short handover period in the main ward area.

FY: David was in a visible room, Keri had alerted she had concerns he’d taken his blood pressure cuff off and may dislodge the IV treatment, so may need some more sedation. Keri and I had a brief conversation about that, had consideration for several minutes, always a risk giving more sedation of drugs versus giving treatment. Considering if he did rip the cannula out he’d get no treatment, he had a small dose of IV Lorazepam which is more predictable in its action given by IV.

C: Obviously at some stage view was taken he ought to go to AAU. Is that right?

FY: We’re going right back a couple hours, that was the original plan… acute kidney injury, is acute medical admission to an acute medical ward, or I guess, going back, no reason he wouldn’t be suitable for ICU, an acute medical admission on ICU, is still a medical admission.

At some point plan was to go to AAU, assuming treatment would work and his NEWS score got better

C: If he didn’t make progress, you would keep him on the Emergency Department?

FY: If he didn’t make progress after 2/2.5 litres of fluids we’d have another conversation with the Registrar and make a referral, in David’s case would be to the main Intensive Care Team. In the Trust we refer people to Outreach of the Intensive Care Team if they’ll be transferred to a ward with a NEWS score of 5 or more. I don’t know if that’s Trust policy or ED Policy, but that’s what we do.

C: So, did you think he ought not go to AAU?

FY: I thought he should go to AAU with the condition he had, with the caveat if he didn’t improve he’d be suitable to go to ICU.

C: OK, when did you, I said form that view? You’d already been liaising with Dr Chase, when did you harden the view he ought to go to the ward?

FY: I suppose at the time I left and handed over the department that was the prevailing plan. There’s a slight logistical nature to that in terms of ED and the 4 hour target, the plan needs to be recorded that a bed has been requested for admission, but that doesn’t necessitate the patient is ready to go in the bed.

Very early on, subsequent to my initial conversation with Keri, we’d had a long conversation about potential social ramifications. I assured we’d not be discharging from the Emergency Department.

C: So, he’s going to go to a ward and the natural point is the end of your shift when you’re handing over to someone else?

FY: Yes, essentially I did the handover with the Doctor at David’s bedside, to introduce the doctor to Keri, explained the plan where we were waiting for the Medical Registrar. At the point I left I had no indication of when bed available, or he was moving or anything like that.

Part of the conversation with Keri much earlier on at first meeting was there was a reasonable chance he’d remain in the Emergency Department all evening until the morning. In that conversation, it was not specifically for clinical reasons but logistical bed availability.

C: OK, and you hand over to the ED Registrar, you note in your statement and then you effectively finish in terms of your involvement?

FY: Yes I handed over to the registrar, think I had a brief conversation subsequent to that with Keri. I’d spent a number of hours with her at that point, was more a colleague to a colleague who’d had a terrible day, to check she was OK.

C: Just let me consult my notes please [short pause] Thank you for taking me through the chronology, will take you to specific points.

In terms of agitation and clinical assessment, you mentioned that when you were taking the pulse, not mentioned in your statement, but you mentioned in giving evidence, you conducted a physical examination?

FY: The state examination of injuries [think he said, hard to hear]

C: Did you listen to the chest?

FY: I didn’t no

C: Why?

FY: He had no respiratory symptoms or signs on his observation chart

C: So there was no reason, is that your position?

FY: At the time, yes. If someone came in with a isolated head injury or leg injury I wouldn’t necessarily listen to their chest… is evidence base about auscultation of chests in the Emergency Department … I know it’s hindsight, but it makes you no more or less likely to diagnose pneumonia, that was a large scale meta-analysis [I think he said in 2007, hard to hear]

Dr Young added that his primary reason for not listening to David’s chest was that all his observations, his respiratory rate and oxygen saturation in air did not indicate any respiratory distress. The coroner asked Dr Young his view on the pathologist’s finding that David’s cause of death was bilateral pneumonia and he responses that he was “quite surprised to read that, such significant bilateral pneumonic findings with no respiratory symptoms in a 40 year old man was quite unusual”.

In further probing from the coroner he caveated that he is not a pathologist, but mentioned David had gone through 9 minutes of CPR on the ward and he had a history of reflux, he detailed how patients can aspirate the contents of their stomach during CPR when no muscles are engaged, and questioned whether the post mortem was skewed subsequent to the cardiac arrest. Something he described as a reasonable medical question that he didn’t have an answer to.

Asked by the coroner if his working diagnosis remained the same throughout, he confirmed it did, agreeing with the coroner’s summary of rewarming, hypothermia and kidney injury.

The coroner asked him if he had an alternative cause of death, and Dr Young responded “as with lots of things I think it would be multifactorial”. He said he’d explored that a little in his addendum statement and he referenced one of the court experts Dr Breen’s statement considering metabolic acidic washout syndrome. Dr Young considered that might have played a part in what occurred.

FY: I believe that has some part with what occurred. Very difficult, don’t know whether a sudden event occurred or there was a step down decline in blood pressure, oxygen levels occurred prior to that. We don’t have that information, hard to make a more qualified statement we don’t have it.

C: No, thank you. At time sedatives was given was an assessment conducted specifically at those times?

FY: Assessment? Just that he was agitated, I said yes I agree, Keri hadn’t really left, she went for one small walk the whole time, we had conversation at bedside and she agreed, she’d been helping to stop that IV cannula in his right arm from dislodging when the blood pressure cuff came off

C: In relation to pain score of 0 throughout his time in the Emergency Department, we discussed it’s subjective

FY: Is subjective. I’m not person documenting NEWS scores… at times I saw David he certainly didn’t appear to be in any pain. Keri and I had conversation about paracetamol once, happy to do that, but didn’t want to introduce different agents… had introduced Midazolam and Lorazepam

I asked our nurse to let me know if any pain or discomfort, I had no conversation with our nurse about any pain, borne out by early warning chart. Is agitation pain, is it not pain, that’s the risk.

Dr Young added that he would have expected pain to have caused David to have tachycardia or to have raised his blood pressure or heart rate, or to have indicated a spike on the monitoring that the nurses would normally assess.

Court then adjourned for a 5 minute afternoon break, before returning with a discussion about timetabling and possible availability of the new witness.

It was then over to Ciara Bartlam for David’s family to ask questions of the Emergency Department Consultant, Dr Fraser Young.

She introduced herself and said her plan was to follow the chronology and pick up on a few things, but she did not plan to repeat things that had been said before and she assured Dr Young he was not required to repeat evidence he had already given.

CB: If we start with the pre-hospital period, three documents in front of you at once, you have NEWS scores summary from Dr Athey; also the Royal College of Physicians NEWS scores chart, and please open records bundle to page 2

What you can see is part of the ambulance records, pre-dated David’s admission, was taken by, on the right side, taken by Emma Brindley at 4pm on 12 January. Can you confirm that is what you’re looking at as well?

Dr Young confirms it is.

CB: If we look at the NEWS score as well from 5:32pm, we can see one of the parameters that couldn’t be taken at that time was temperature, is that correct?

FY: Yes

CB: If we look the ambulance records, they’d managed take David’s temperature and it’s recorded at 34.9 degrees C. Looking at this NEWS chart, would you agree that puts David in a category that would normally score 3 points?

FY: Yes

CB: In terms of David’s temperature would you also agree on the balance of probabilities it remained about 34.9 at 5:30pm, but obviously that wasn’t taken?

FY: Yes, the next recording was 33.8, so in between

CB: Would you agree then, that would be a 3 point?

FY: Yes, it has to be

CB: In terms of response, what you’re looking at then is hourly observations, is that correct?

FY: I assume [can’t hear]

CB: Of course we know observations weren’t taken for another 3.5 hours

FY nods

CB: In terms of that temperature being taken, were you aware the ambulance service had taken that temperature?

FY: Not from our triage no, I was presented with this set from the nurse

CB: The nurse I believe was Leah Butler?

FY: Yes

CB: When presented with that set did you ask whether any reasonable adjustments had been made to take those observations?

FY: From the nurse directly no, but that conversation is what prompted me to come to the patient, to David and I spoke to Keri about adjustments

With regards that set of observations, no I didn’t fully understand what the barriers were to taking observations.

CB: Did you at any point offer to take those observations yourself at that early stage?

FY: No. The first time when I spoke to Keri it prompted a conversation about just insisting doing more things to him, or go down the sedation route

CB: Would you agree between the ambulance observations recorded respiratory rate of 16 and observations taken at 5:32pm, an hour and half later, which recorded respiratory rate as 24, there had been something of a jump?

FY: Uh hum

CB: What’s the significance of that? Can you explain?

FY: Agitation

CB: Agitation. You also explained there was no incidence when David was in respiratory distress, would you agree a respiratory rate of 24 was some level of distress from 16?

FY: Represents a change in his respiratory function, not necessarily distress, hyperventilating, from stimulus of having just arrived.

CB: Would you agree in order to know whether or not was respiratory distress you’d have had to have done a hands on physical examination of David?

FY: Potentially, in that conversation with Keri, his respiratory rate was calm and peaceful, 17, certainly at no point when I saw David was he in respiratory distress

CB: Would you agree you have to get close enough to see if he is in respiratory distress?

FY: Yes, his chest rising and falling

CB: When David was under blankets, would you agree it was impossible to tell?

FY: [missed start] I see 50 patients a day to observe their breathing pattern.

CB: His respiratory rate went down to 17, could that respiratory rate be brought down by Midazolam?

FY: Yes when was Midazolam given?

CB: 18:25

FY: Yes

CB: And is that likely to be the reason for the fall in respiratory rate?

FY: I don’t believe was continuous … Midazolam is the shortest acting of the benzodiazepines we have, more likely to represent what his respiratory rate was

CB: At any time you saw David, was he alert as would be described on a NEWS score?

FY: No, at sleep at best, and making noises, but not alert

CB: Thank you. You mentioned you were asked to see David because of difficulty getting observations. Was there any other reason, you as a specialist?

FY: His NEWS score, and he was a vulnerable adult, potentially also because of the situation that had just occurred, required response and intervention in a sensitive fashion both for David and Keri and everyone all around. Didn’t fully understand until conversation with Keri… part of global parcel of reasoning.

CB: Was it also because perceived by ambulance as a case that required urgent care?

FY: I wouldn’t have assumed that, if any ambulance staff are concerned about urgent care or resuscitation, they would pre-alert our resus room and we’d make a space for them in different area to receive them. Wouldn’t infer he’s arrived without resus alert, they’d made assessment, they did not bring him to the resuscitation area.

CB: First page of ambulance records, very bottom says initial acuity on left hand side, urgent level emergency care

FY: Yes

CB: On a scale of urgency, that’s someone who needs be seen pretty quickly?

FY: I don’t know the categories the Ambulance Service use, if pre-alerted… I’m not entirely sure what 3 means on the ambulance test

CB: Thank you. Moving on then to your assessment, in terms of the impact of David lacking capacity to make decisions around medical treatment; it’s right isn’t it that all clinical decisions needed to go through Keri without exception, is that right?

FY: Yes

CB: A decision not to escalate to ICU would need to go thru Keri?

FY: Yes

CB: Were you aware David had a hospital passport?

FY: I don’t believe so, was aware of his communication device was there, but wasn’t aware of the passport

CB: Statement of Dr Athey refers to learning disability champions within the emergency department. Was there any form of Learning Disability Champion within Hull Emergency Department at the time?

FY: Essentially would be me as Emergency Department [missed], part of my non clinical role is champion for drugs, alcohol, vulnerable adults, [lists other areas, couldn’t hear] that’s my remit

CB: That’s still the case now?

FY: Yes

CB: If I take you to the assessment, in bundle, examination details says rousable to voice, ABC … just want to clarify something in your evidence. You said this had taken place at 9 o’clock, this appears to relate to that initial assessment?

FY: Yes, end of bed with Keri at the initial time… after conversations I had with Keri this was recorded in one session, I did not interact with the computer system again.

CB: Do you agree you should have recorded more regularly?

FY: I agree, there should be document contemporaneously  

CB: Dr Athey, paragraph 3.27 of his report, says initial attempt at physical examination is limited by agitation, led to administration of sedative medication, which is your evidence. As such it was generic and lacked detail beyond establishing that Mr Lodge was breathing, had a circulation and was able to move his limbs. Would you agree with that statement?

FY: Yes

CB: In final sentence Dr Athey says from what is known about his limb contractures… the phrase moving all limbs normally, is likely to be incorrect. Would you also agree with that?

FY: I don’t know, I had conversation with Keri at the same time, is he moving as normal and answer was yes, no unilateral weakness, specially in the context of head injury

CB: There was nothing you examined or saw personally to say in fact his limbs were moving normally?

FY: No was an amalgamation of triage, ambulance observation and conversation with Keri

CB: You heard Keri’s statement earlier, she describes in it that David was weaker than usual, and less alert than usual. Would you agree that was stated to you at time?

FY: Yes, she stated to me

CB: In terms of agitation, were you aware at the time whether he was more or less agitated than usual?

FY: Was aware immediately prior to seeing him, our nurse had tried to get observations and he was agitated… not sure what normal level of agitation was… heard from ambulance service [missed]

CB: I’ll ask the question straight, I hope it doesn’t seem abrupt. David had a long lie, up to 4 days known to you at the time?

FY: Yes

CB: Possibility he’s not eaten or drunk anything for up to 4 days, definitely a couple of days, would you agree?

Dr Yorke nods

CB: On Keri’s evidence David is weaker than usual, less alert than usual. Balancing that picture did it occur to you, I’ll just take observations anyway, agitation or not, because it’s a very serious situation?

FY: Don’t disagree with that, balancing what do we do here, just do them anyway, what does that lead to, would be my next question. Likely to be hypotensive, from story, at that point left with what do we do to treat that now, holding him down again to force needle cannula into his arm?

From discussions Keri and I had, he’s attached to drip and pulled blood pressure cuff off at some point earlier and later, ripped out and go through the same process again, I think was significant risk of assaulting him again and again.

But getting, I was comfortable the way sedation plan came up with would allow us to get proper observations and allow proper treatment, IV fluids, cannula, bloods, far more accurate information then.

CB: I suppose there are two aspects to that, what you are you describing is a best interest’s decision?

FY: Yes

CB: And that should have been recorded?

FY: Yes. Everything I did was in discussion with Keri…

CB: Given what you say about the short acting nature of Midazolam, would you agree it was unreasonable then for fluids to be delayed for over 3.5 hours, given he’s hypotensive?

FY: As I said in evidence earlier its quite a long time, don’t know whether the effect of it being noted was delayed in terms of nurse checking and coming back, I don’t know. All I can attest is the plan was when able to get observations tell me, I’ll come and get bloods done. I can’t say, when I was sought for that I came straight away.

CB: In terms of your other part of your initial assessment, if go to page 7 you have working diagnoses 1) significant new social crisis 2) difficult behavioural management situation 3) acute kidney injury and dehydration and 4) head injury.

Firstly, significance of new social crisis and behavioural management situation. What do those things mean?

FY: I wrote it after a conversation with Keri, she was upset at the time, given events of previous hours. Protracted conversation about what he’d eat and drink, Peter was often one who’d feed him etc … she was quite worried about that, was more to highlight he needs a lot of social care input, what discussed with Keri, to make sure that was highlighted, she was worried so some degree, fluids and then won’t be able to discharge him home, to highlight through to next teams, working with family and social care would be large part of management.

CB: Would you agree having 1 and 2 suggest they’re priority issues?

FY: No, it’s just the order I wrote them down in

CB: Would you agree to another clinician looking at that, it would suggest they are priority issues

FY: Not necessarily

CB: In the list there’s no mention of pneumonia, will see what Dr Athey said at 3.56… do you agree?

FY: Firstly yes, I’m not sure they all applied to the Emergency Department, is all part of an assessment.

Ms Bartlam asks further questions and Dr Young confirms he knew about David’ past admission for aspiration pneumonia. He said at the time David had no respiratory symptoms. Ciara asked Dr Young if he agreed with Keri’s suggestion that David might have been too weak to cough and Dr Young did.

The coroner interjects and says he will refer the witness to paragraph 3.56 in Dr Athey’s report.

C: An assessment of Mr Lodge to a standard sufficient to exclude an infective process involving the chest, abdomen, urinary tract and skin pressure areas was required and did not occur during his ED stay. This represents substandard care in my opinion. You agreed with that opinion?

FY: I agreed that would represent good care, but not all of that would necessarily have needed to occur in the Emergency Department. Some more of that is difficult, what you’re considering counts as part of your investigation of infections, was part of reason for blood tests… whether significant evidence at that point, there wasn’t. I was sufficiently happy with blood tests and observations, chest observations, didn’t suggest was infective process there

CB: Would you agree that all needs to happen as soon as possible?

FY: I agree, it doesn’t matter to David where it happened

CB: Would you agree you could have done that at 9pm when David was allowing you to take bloods?

FY: Do what

CB: To assess his chest

FY: I could have done but I don’t believe would have led to ….[missed]

CB: Why isn’t pneumonia referenced anywhere in the records?

FY: David hadn’t presented with any respiratory symptoms, so I didn’t consider a diagnosis of pneumonia

CB: Would you agree, that should have been considered, in light of the history?

FY: I wouldn’t necessarily agree with that, no. History is previously been in hospital with pneumonia on which he was on ICU, ventilated … he had no ventilation failure clinically, whilst aware he previously had significant pneumonia… he had no hypoxia or oxygen requirement at all during any point in the ED…. In tandem with further investigations and his bloods for example don’t demonstrate a significant… oxygen levels ok, I clinically felt reasonable, it wasn’t immediately obvious he had pneumonia

CB: Dr Athey’s view on history was, the history of a prolonged period of immobilisation on the floor, hypothermia, past GORD and past aspiration pneumonia, requiring ITU admission, should have alerted the ED clinician to an increased risk of aspiration pneumonia. For complete clarity, do you agree or not?

FY: I agree with the statement should have been considered, and by elements of what spoke about, it did

CB: Would you agree with the rule if not recorded it didn’t happen at the time?

FY: Potentially a whole host of negative findings could be recorded, wouldn’t be mine or my colleagues practice to record every negative finding

CB: In terms of management plan, you said CT head scan as possibility, this phrase that appears on third paragraph down, I think there’s a typo here, for medical admission in any event is that correct?

FY: Yes

CB: You’ll know what Dr Athey interpreted this as, we’re not considering anything but admission to AAU, not considering Critical Care, ICU for example. What’s your opinion of that?

FY: On what I meant or he meant?

CB: What you meant

FY: Not for hospital discharge

CB: Keri described conversation generally with you, whether investigation necessary, 1.79 she said he, Dr Young explained he did not think it was…. Ask medics about it on the ward. Would you agree at that point, the only communication with David’s family was admission onto the ward?

FY: I discussed lots with Keri, including sedation, getting bloods, giving IV fluids, rewarming required, didn’t know at that time, possibility further investigations if required. We would be observing from perspective of head injury, whether deteriorate… Keri and I discussed disruption of things, taking elsewhere in hospital, get in scanner etc immediate benefit wasn’t obvious clinically, runs risk of significant distress and agitation

CB: Thank you. I’m asking specifically about the ward and where David was going. Would you accept the only discussion you had was admission to ward, a medical admission?

FY: Yes… the only conversation we had was get him treatment, medical doctors, medical ward, wouldn’t be discharged. That was the conversation.

CB: Do you agree in notes is absolutely no discussion about ICU or Critical Care for David.

FY: Yes, in fairness, as I said he would have been suitable for ICU after challenge of treatment, to see response to it. Wouldn’t routinely discuss ICU suitability with any patients unless thought it wasn’t suitable, at that point would be discussion and respect forms. ICU was definitely an option but I wouldn’t have said to Keri or David or any of the other 20 patients I saw that night if you get worse that’s an option.

CB: Would you agree precisely because David lacked capacity on medical treatment, and decision might need be made very quickly, that conversation should have taken place and been documented?

FY: To what view? To see whether he was suitable for ICU or not? He’d just been on ICU the previous year.

CB: At any point did you consider this person might need to go to ICU?

FY: Yes

CB: Why wasn’t that documented?

FY: At the time I saw him he hadn’t completed a course of treatment, so couldn’t say

CB: Would you agree if you’re considering ICU admission that was a conversation you ought to be having with Keri?

FY: Yes if I was considering admission, but it’s difficult to have a conversation in advance, when treatment is given

CB: Did you think at any point you ought to have that conversation with Keri?

FY: At time I left he hadn’t had full treatment, clinically nursing staff, non-numerical and evidence base, but if his NEWS score was 8 at time of finishing treatment and moving to ward, that’s a conversation I’d have with patient or their advocate

CB: In actual fact at the time David was moved to the ward his NEWS was 8

FY: I misinterpreted earlier statement, I understand shortly after that his NEWS was 4. At NEWS of 8 I would not have moved David from the A&E to the ward, pending at least review of medical registrar and/or ICU, but I was not there at that time.

CB: Was all that you just described communicated to the ED doctor in charge?

FY: Yes, this is treatment, would be suitable for everything, no Respect Form, awaiting medical registrar review. I didn’t anticipate David’s move to the ward would have been so timely as it was he went much sooner than I thought he would, partly because I’d spoken to the Site Matron of the hospital about David and Keri and Keri’s desire to stay with David, they’d found a side room to go to, but I wasn’t there for decision making…

CB: Would you agree that plan in your mind really ought to have been documented on handover?

FY: Handover? Certainly on the documents, yes. We don’t have a documented handover per se, as A&E department, is unusual patients are handed over. I also think would apply to David’s case as 40 year old man, why wouldn’t he be for escalation?

CB: Certainly, that’s Keri’s position

FY: I agree

CB: In terms of what described earlier with conversation with ICU Consultant Dr Lad, did you or he know at the time he’d previously treated David? When having the conversation about Midazolam?

FY: Yes, good couple of years ago, I popped in to check BNF guide, dosing regimes and weight, sense checked with him, got this gentleman, this makes sense doesn’t it, he said yes. He said he’d previously been involved during an inpatient stay in ICU where he’d required sedation to manage agitation I believe. Wasn’t in depth discussion, wasn’t referral, was a brief conversation where I’d talked about using drug in slightly unconventional route in an adult

CB: Given difficulties getting observations, did you consider saying to Dr Lad would you come speak to Keri or review David?

FY: At the time no, would just be asking someone else to come and do my workload for me. Understand questions, early ICU referral, what would that have resulted in, let’s admit, I don’t know, or deliver treatment and see what goes on, far more likely practice in our department where I’ve worked for 14 years, but I don’t know in fairness to your question.

CB: What you said earlier about continuous monitoring in ED, would you accept certain parameters in NEWS can’t be done unless someone visits patients, such as response to pain and [missed]?

FY: Yes

Ms Bartlam asked a question about continuous monitoring when a NEWS score is elevated at 7 or higher. I missed his answer.

CB: When you described continuous monitoring on the Emergency Department, that’s not the continuous monitoring envisaged in this document is it? That’s having someone on hand and taking notice of the patient?

FY: I think it depends on your definition of that, someone on hand, or someone sitting 1-1, logistically would be significant, in A&E department with 140 patients, at any time 40 patients with NEWS scores of 7 or more, I don’t think logistically would make sense … I wanted David to go to the room he did too, people walking past all the time, and yes walking past is walking past and paying attention is paying attention….

CB: You described yourself fulfilling the role of the person who has clinical care competencies, including advanced airway management skills

FY: Yes

CB: In terms of your contact with David is it fair to say you didn’t reassess him from 9 o’clock?

FY: At his bedside no

CB: So would you agree after 9 o’clock David didn’t get that on the Emergency Department?

FY: He was continuously getting treatment, these observations, I was getting updates from the nurse about David. Medical registrar would do more detailed assessment in ED… I think again, comes to slightly more difficult thing of what is the function of an Emergency Department, deliver initial treatment, check responsive, absolutely of which he’d not made a response yet and treatment was ongoing at the time we’re talking about. In terms of patients in general, reviewing and re-reviewing, ward rounding is out of the scope of the Emergency Department

CB: I’ll take you to the times observations taken

She takes Dr Young to the records

CB: Would you agree this page effectively catalogues when observations are due or overdue, and frequency of which they should be taken?

FY: It does appear to, I’m not familiar with it, its nursing based not medical based, it’s a system I don’t use

CB: Would you agree if look third row from bottom of page 62 we have line, one green priority, observations due, this then catalogues when observations are requested, 9:13pm, when completed 9:37pm and then far right details last recorded Early Warning Sign 9, recorded at 12 January 2022 20:53, frequency 30 minutes. Would you agree appears from this record observations were indicated at frequency of 30 minutes from 9pm onwards

FY: As very unfamiliar with system, read line you’ve just read out, it does appear to make sense. Seeing for first time, it does say those words.

CB: Yes if we look at Dr Athey’s summary of Early Warning Scores, within his report, 20:53, 21:37, 22:29, 23:07 and 00:48 that none of those observations were 30 minutes after the previous one.

Dr Young nodded.

CB: Would you also agree between those last two observations at 23:07 and 00:48 there appear to be two missed opportunities for observations to have taken place

FY: I’m not sure

CB: Let’s walk through it, 30 minutes after 23:07 would be 23:37 and 30 minutes after that would be 00:07

FY: I’m sure I’m confusing line above… 22:49 done at

C: Sorry I’m not following you there, I understand Ms Bartlam’s question. On Dr Athey’s report, or other place Ms Lyle referred to earlier, in this table in relation to times observations taken. Ms Bartlam is asking you 23:07 second from last one, time observations taken, generates score of 9

FY: Yes

C: And unless Ms Bartlam corrects me I understand the frequency recommended, have question how that 30 minutes is generated, the mischief is Ms Bartlam fairly asking in relation to 23:07 indication, to extent recommended every 30 minutes, 30 minutes after 23:37 and 00:07, when you look at the last column its 00:48

FY: No, it’s the column before confusing me

C: In relation to that question, please answer that question

FY: If it says every 30 minutes, spreadsheet in front appears to suggest it’s not every 30 minutes. I don’t know the system, what alerts, but does appear to indicate missed

CB: In terms of overarching responsibility for David’s care, whose responsibility is it to ensure observations are completed?

FY: Senior Nurse or Charge Nurse for the nursing unit. System is nerve centre, has automated system to flag up what overdue, it’s not a system I interact with, can’t do that justice for the benefit of the court

CB: In relation to later part of chronology, you said nurses would get me if needed to have a look … if you go to page 67 of those records, this is another record in Nerve Centre, not asking you interpret, second to bottom row 1016, at 22:27 written in retrospect, care taken over from day staff, introduced staff to patient and his daughter present… reads more

Observation records and NEWS 9 points, hypothermic with temperature of 33.2 and hypotensive blood pressure 79/54, escalated to ED Consultant and Ward Sister. Patient care needs given including mouth care, don’t know what that means, don’t know if you have any insight?

FY: If dry chapped lips on mouth would use small lollipop swab to moisten inside mouth

CB: On continuous monitoring… close monitoring… some other bits including initial assessment completed, on that occasion, nurse recording suggested escalated to ED Consultant

FY: Uh hum

CB: Were those results at roughly half past 10 escalated to you?

FY: I suspect so, I recall occasions when someone has escalated to me, I don’t recall exact times but if they’ve written that I suspect so

CB: In terms of what you did with that information, there’s no record of you doing anything with it, do you agree?

FY: This isn’t my record

CB: There’s no record of any further review of David, your evidence was only review took place at 9 o’clock.

FY: Uh hum

CB: Would you agree on this escalation of information that review should have taken place at half past 10?

FY: At half 10 we’d have been half way thru IV therapies, system tells them to escalate, as it should, that’s where observations are, we’d hope to see improvement with warming and fluid, was significantly more initial therapy treatment I’d planned to go. 10 o’clock would have been after sight of blood tests, knew … had chat with nurse about it, right lets press on with the treatment

CB: In terms of contact with ICU, did you consider at all at this point, half past 10 getting back in touch with ICU Consultant Dr Lad who you spoke to previously about ICU referral?

FY: Two things, I’m not sure Dr Lad was the ICU Consultant at that time, just happened to know him… think this was incomplete initial therapy treatment, needed assessment after completed, and hadn’t completed, needed to rewarm and get that fluid into him and then see where we were

CB: At this point speaking where at, you said earlier that by half 10 you’d have expected to see response to fluids at that point?

FY: Yes I would have liked that. Is it a massive outlier that we didn’t? No

CB: Turning to NEWS scores in Dr Athey’s report, would you agree David’s blood pressure, he has remained hypotensive significantly throughout that period?

FY: Yes, slight trend, slightly higher, not highest in world but I’d say that’s the trajectory when discussing things

CB: So in terms of progress, the progress he’s made on fluids is minimal. Would you agree?

FY: Slow. As said in evidence earlier, potentially 4 days losing fluid, 4 days of fluid to catch up on. 2 litres intravenous fluids seems a lot, suspect David had quite a lot of fluid left to fill

CB: In terms of that last NEWS score in the Emergency Department at 00:48. Are you able to tell us when you left the ED that night?

FY: I don’t know

CB: Would you have seen this record, the one taken at 00:50?

FY: Not necessarily, no

CB: At the time of you leaving the department, given NEWS score 8, would you agree you should have gone back and reviewed David before leaving?

FY: Not necessarily, point of review would be following initial treatment therapy which hadn’t concluded at that time. A true response needed to occur, from resuscitation point of view, in tandem with that, there’s a pathway and in-depth medical assessment, the medical team were highlighted a couple of times, I don’t know what workloads occurred. Part of handover, we’re doing this, will see what end result of initial fluid is, that’s handover and review when we get there

CB: In terms of treatment for pneumonia, is there any reason why treatment for all these things couldn’t have happened at once, pneumonia, dehydration, hypotension?

FY: Treatment is the same thing, is fluid given. I didn’t appreciate he had pneumonia.

CB: I appreciate that

FY: Would do the same thing, if you came to hospital, you’d get antibiotic and fluid at same time, consecutively [I think he said]

CB: In relation to NEWS finally, on the scores, we’ve got as well the score at 01:20. Would you agree on face of it this is brought down considerably by the alert value? When previously he scored 3 points because of pain, but here he’s marked alert?

FY: I agree, yes

CB: So if this was in response to pain outcome on NEWS, would be 7?

FY: Yes

CB: If you’d seen NEWS score of 4, 49 minutes after NEWS score of 8 would that be a surprise to you, in the circumstances?

FY: Difficult to tell, such sudden jump down, how suddenly got better, we often see if cardiac dysrhythmia sorted itself out, surprises me significantly 2.5 litres of fluid and completely become alert, not least in context someone not long before had another dose of benzodiazepines to help the IV fluids go in. Those observations were not done in our department

CB: If you’d remained in charge of David’s care at that point and were told he had NEWS score of 4, what would you have done at that point?

FY: Don’t think I’d have run to his bedside to check that, but would pull up, check and say alert, not alert?

CB: NEWS score of 8 seemed reasonable in line with his presentation?

FY: Yes, I said in evidence earlier I believe transferring a patient out of the Emergency Department with a NEWS score of 8 or 9, who hadn’t had further plan made, I would have been uncomfortable

CB: I’ve just got 2 questions for you left, in terms of your converersation with Dr Chase, did you pass any of that information to Dr Chase about NEWS scores and moving from the department?

FY: Not at the time, was significantly earlier conversation with Dr Chase, had no idea patient would leave the department so soon as they did do, so no…. [missed]

CB: final question, might be series of questions about medical cause of death. In terms of what you said about bilateral pneumonia and the pathologist report, would you defer to pathologist on cause of death in this case?

FY: Have to take findings as cause in this case… they surprise me….

CB: In relation to another aspect of this 1a) bilateral pneumonia, is the possibility to put in part 2 underlying conditions. Would you agree if David was able to summon help in the time period, 4 days, or however long he’d lied next to his father, on balance of probabilities, would you agree he’d not have contracted pneumonia and then died?

FY: Lot of variables… if he was able to summon help earlier the position he would be in, would be better

CB: On the balance of probabilities can you say in David’s case that was likely to be the case?

FY: Generally, yes… [missed section] … generally in medicine the earlier you get help, treatment, assessment, the better.

There was then a discussion about timetabling, at this point it was shortly after 4:30om and it was agreed that the court would continue.

It was over to Ms Lyle to ask questions of her witness, Dr Young.

SL: You’ve just been asked questions about the observations….turning to the NEWS scores, got NEWS scores at 00:48 hours, like to compare that to NEWS score on 23:07, do you have a copy of the chart with you?

Dr Young confirms he has Dr Athey’s report.

SL: In relation to that we’ve got the observation scores and NEWS score at 23:07, if just look at that, NEWS score of 9, look at those highlighted in orange

FY: Blood pressure 80/66 at that point

SL: Then observations 00:48 84/55. Would you describe that as an improvement or not?

FY: If you give me two sets of observations for a patient randomly, I wouldn’t say that represents significant improvement. Over trend of period of time from 70s to now in 80s, we can argue alert of … I’d say represent move from 70s to 80s to 90s

SL: Look at it that way, on colour chart gone from orange red to lighter red. My presumption is that shows some improvement, would you agree with that?

FY: Within that parameter yes, which was predominantly one we were worried about, would see that as positive

SL: Heart rate of 75 at 23:07 and then got heart rate at 00:48 at 99 and then heart rate at 01:19 and its 101 so slight increase?

FY: That’s a slight increase yes

SL: If go back look temperature for example 23:07 got 33.5 and then look score 01:19 got 35.1 so again some improvement would you agree with that?

FY: Quite a significant improvement actually, big physiological difference between temperature of 34 or over

SL: At that point was transfer to medical ward and a further set of observations were taken, that’s from your statement. Could it be why there’s been a change in alertness, at that point he’s been transferred from one department to another and observations taken. Could that be reason he’s alert at that point? I know you weren’t present.

FY: Yes, it could

SL: So even though NEWS score of 4, it’s not only the alertness that’s affected that score, would you agree slight improvement of some of the observations being taken at that point?

FY: Temperature reflects it, blood pressure reflects partially

Ms Lyle asked if there was anything to indicate a significant decline across all observations in the A&E department. Dr Young said that they were “worrisome to begin with” but he didn’t think there had been significant decline.

SL: In your opinion, when you were on duty up to the point you left, was there any clinical indication a referral should be made to ICU?

FY: At the time, or in retrospect or both?

SL: At the time when you were dealing with him

FY: I wanted him to complete his initial therapy as described … NEWS score of 8 concerns me for leaving the A&E department, that said 01:19 first set of observations in the medical department, he had a NEWS score of 4 I think, I’d have been happy for him to go to ward.

C: In retrospect?

FY: Yes, I didn’t have those observations, if those observations had been his observations in A&E after treatment, then at that point it is not in our internal criteria to call for intensivist support

SL: At any point before you left and midnight, now looking at the figures, numbers, was there any impact upon David by transferring him to AAU when looking at those figures?

FY: In terms of what … his observations got better from transfer to AAU, physiologically raises questions obviously but that’s what the numbers suggest, obviously it’s more complex than that in real life

SL: So although you’ve indicated in your evidence you’d have expected medical review prior to transfer, you agree that’s not had an impact on numbers when he was transferred?

FY: On numbers

SL: Observations

FY: No

Ms Lyle asked about antibiotics and if at any point David was under his care, was there any point that antibiotics were indicated and should be prescribed. Dr Young said not from the information at the time.

FY: Not from information at the time, no, no display of symptoms, no rigors, coughs, breathlessness and was somewhat reassured by blood findings, in own right none of these things are foolproof but bringing together didn’t require antibiotics.

SL: Decision made on observations taken and blood results?

FY: Clinical history and blood test results yeh, respiratory function of all his observations did not indicate pneumonia

SL: In terms of electrolytes and potassium results, if we could just refer to that … in relation to information you have, bloods taken around 9pm obviously, not bloods taken later, was there anything to indicate any abnormality at that point that would herald a cardiac arrest?

FY: Not in themselves no, number of abnormalities in blood tests across several domains but no significant outlier of something impedingly terrible was going to happen, if that was case I’d have taken action and explained that to Keri. After these blood tests I did update her.

SL: In relation to transfer from A&E, to AAU, had he been transferred before 01:15 hours, are you able to confirm whether a different treatment plan would have been put in place at that point, or is it likely to be exactly same as it was?

Dr Young asks Ms Lyle to repeat her question before responding that it is difficult, adding in retrospect potentially not.

FY: If initial treatment resulted in observations at 01:19 if stayed in A&E somewhat reassured by that, but of course that’s not what happened, he went to AAU and then the observations were better.

C: Is there a limitation on you asking that question? Question was in relation to transfer, would treatment plan provided been any different in your opinion… is there limitation?

FY: Limitation, there’s variables there, may have been different, it may have been the same, as it were I was the last doctor prior to the cardiac arrest to see David. It’s difficult to know. Questions to ask a medical doctor.

Ms Lyle says that she will put those questions to Dr Chase.

SL: Just in relation to delay in any treatment being provided. just looking at times, the 18:25 point of time, Midazolam liquid administered at that point?

FY: Yes

SL: Then first set observations were 20:53 hours

FY: First full set yes

SL: You indicated you’d expect the Midazolam to take effect, did you say within 2 hours in your evidence?

FY: Yes, difference in concentration… certainly not my expertise… I would have thought in most patients you’d reach a sedated effect significantly earlier than that time gap.

The unknown to me is I don’t know if he was sedated significantly earlier and that is the time the nurse got around to checking, or the physiological process made difference in way he’s metabolised and absorbed that.

SL: So, when you say 2 hours …

FY: If I have any times on there it’s from drug manufacturers’ data

Ms Bartlam interjected to say that her note of Dr Young’s evidence was he would expect sedation to take place sooner, around the one hour mark. Dr Young agreed with her.

The coroner asked to clarify that, noting Dr Young appeared to agree with Ms Bartlam.

FY: I expect at about the hour mark should have reasonable sedation effect, but dynamics of that hard to retrospectively apply

SL: In that case sir no further questions, was the two hour mark I was referring to

The coroner thanked Dr Young for his “marathon session” giving evidence and he was released shortly before 5pm.